ATI- Chapter 45- Sensory Perception

For clients who are disoriented:

- Call clients by name and identify yourself - maintain eye contact at eye level - use brief, simple sentences - ask only one question at a time - allow plenty of time for clients to respond - give directions one step at a time - avoid lengthy conversations - provide for adequate sleep and pain management

A nurse is reviewing instructions with a client who has a hearing loss and has just started wearing hearing aids. Which of the following statements should the nurse identify as an indication that the client understands the instructions?

A. "I use a damp cloth to clean the outside part of my hearing aids" B. "I clean the ear molds of my hearing aids with rubbing alcohol" C. "I keep the volume of my hearing aids turned up so I can hear better" D. "I take the batteries out of my hearing aids when I take them off at night" *D

For Clients who have vision loss:

- Call clients by name before approaching to avoid startling them - identify yourself - stay within clients visual field if they have a partial loss -Give specific information about the location of items or areas of the building -Explain interventions before touching clients - Before leaving, inform client of your departure - Carefully appraise clients clothing, and suggest changes if soiled or torn - Make a radio, television, CD Player, or digital audio player available - Describe the arrangement of the food on the tray before leaving the room

For clients who have aphasia:

- Greet clients and call them by name - make sure only one person speaks at a time - speak clearly and slowly using short sentences and simple words - do not shout -pause between statements to allow time for clients to understand -check for comprehension -tell clients when you do not understand them - ask questions that require simple answers - reinforce verbal with nonverbal communication - allow plenty of time for clients to respond - use methods speech therapists implement, such as a picture chart, to improve communication - acknowledge any frustration in communicating

For Clients who have hearing loss:

- sit and face the client - avoid covering your mouth while speaking - encourage the use of hearing devices - speak slowly and clearly - do not shout - Try lowering vocal pitch before increasing volume - Use brief sentences with simple words - Write down what clients do not understand - Minimize background noise - Ask for a sign language interpreter if necessary

A nurse is caring for a client who has several risk factors for hearing loss. Which of the following medications, that the client currently takes, should alert the nurse to a further risk for ototoxicity? (Select all that apply)

A. Furosemide B. Ibuprofen C. Cimetidine D. Simvastatin E. Amiodarone *A,B

A nurse is caring for a client who had an amphetamine overdose and has sensory overload. Which of the following interventions should the nurse implement?

A. Immediately complete a thorough assessment B. Put the client in a room with a client who has a hearing loss C. Provide a private room and limit stimulation D. Speak at a higher volume to the client and encourage ambulation *C

A nurse is caring for a client who recently had a cerebrovascular accident and has aphasia. Which of the following interventions should the nurse use to promote communication with this client? (Select all that apply)

A. Increase the volume of your voice B. Make sure only one person speaks at a time C. Avoid discouraging the client by saying that you do not understand him D. Allow plenty of time for the client to respond E. Use brief sentences with simple words *B,D,E

A nurse is caring for a client who reports difficulty hearing. Which of the following assessment findings indicate a sensorineural hearing loss in the left ear? (select all that apply)

A. Weber test showing lateralization to the right ear B. Light reflex at 10 oclock in the left ear C. Indications of obstruction in the left ear canal D. Rinne test showing less time for air and bone conduction E. Rinne test showing air conduction less than bone conduction in the left ear *A,D

Sensorineural hearing loss:

Exposure to loud noises, ototoxic medications, aging, acoustic neuroma

Conductive hearing loss:

Obstruction, wax accumulation, tympanic membrane perforation, ear infections, otosclerosis

Vision loss:

Presbyopia, cataracts, glaucoma, diabetic retinopathy, macular degeneration, infection, inflammation, injury, brain tumor