Sensory Perception
A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve VIII?
Whisper something in one ear while occluding the other ear.
A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make?
"You will have a small probe placed in your ear canal during the test."
A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following information should the nurse include?
A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.
A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?
A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?
A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments?
Glaucoma
A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? (Select all that apply.)
A walking cane A walker
A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include? (Select all that apply.)
Inspect the feet every day. Wear closed-toe shoes. Manage glucose levels.
A nurse is providing care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client?
Keep the client's environment free from clutter.
A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? (Select all that apply.)
Loop diuretics NSAIDS Aminoglycoside antibiotics
A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following can decrease with age? (Select all that apply.)
Sour Bitter Salty
A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes?
Hearing loss
A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss? (Select all that apply.)
Asks for questions to be repeated Withdraws from social activities Describes sounds as being muffled
A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client? (Select all that apply.)
Ensure the client wears their hearing aids. Use a sign language interpreter. Communicate using paper and pen. Face the client when speaking.
A nurse is caring for a middle adult client who asks about expected age-related changes. Which of the following sensory changes should the nurse include as an age-related change?
Presbyopia
A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation?
Risk factors for sensory deprivation include experiencing total vision or hearing loss.
A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss? (Select all that apply.)
Trauma to the outer ear Inflammation Cerumen buildup Otitis media
A nurse is reviewing the process of how a refraction assessment is performed with a client. Which of the following statements should the nurse make?
"This test is performed using lenses of various prescription strengths."
A charge nurse is discussing hearing tests with a newly licensed nurse. Which of the following information should the charge nurse include?
A tuning fork is placed against the client's mastoid bone during the Rinne test.
A nurse is caring for a client who states, "My doctor said I should have an EMG. What is that?" Which of the following responses should the nurse make?
"It is a test that determines if there is nerve damage affecting a muscle."
A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make?
"SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin."
A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions?
Availability of aids to enhance vision
A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II?
Check the client's visual acuity using a Snellen chart.
A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.)
Difficulty maintaining attention Agitation Hallucinations Rambling speech
A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia?
Difficulty problem-solving
