Chapter 31: Cognitive and Sensory Alterations

Stimulus

A change in the environment sufficient to evoke a response

Presbycusis

Age related hearing loss

Olfaction

sense of smell

Gustation

sense of taste

What is the meaning of the acronym, FAST for stroke recognition?

Face weakness Arm weakness Speech problems Timing

The nurse in the pediatric clinic is checking the basic visual acuity of a 3 1/2 year old child. The nurse should have the child: a. identify crayon colors b. read the standard Snellen chart c. read a few lines from a children's book d. follow the peripheral movement of an object

a. identify crayon colors

Which of the following occupations poses the least risk of sensory alteration? a. librarian b. welder c. computer programmer d. construction worker

a. librarian

Aphasia

Speech or language impairment

The nurse is performing a Mini-Mental State Examination (MMSE) on an intoxicated patient. What parameters would the nurse evaluate in the patient? Select all that apply. a. Orientation b. Cognitive registration c. Risk of developing cancer d. Risk of developing seizures e.. Levels of alcohol in the blood

a and b

Which nursing diagnosis is most appropriate for a patient with expressive aphasia? a. Impaired verbal communication b. Acute confusion c. Self-care deficit d. Impaired mobility

a. Impaired verbal communication

An older adult patient in a nursing home has visual and hearing losses. The nurse is alert to which of the following signs that represents the effects of sensory deprivation? a. depression b. diminished anxiety c. improved task completion d. decreased need for physical stimulation

a. depression

Which nursing intervention is appropriate for a patient with sensory overload? a. dimming the lights b. performing care a little at a time c. leaving the patient's door open d. rushing to get care done quickly

a. dimming the lights

The nurse recommends follow up auditory testing for a child who was exposed in utero to: a. rubella b. excessive oxygen c. alcohol d. respiratory infection

a. rubella

When caring for a hearing impaired patient, use of which technique by the nurse would facilitate communication? a. speaking clearly with distinct words b. talking slowly to facilitate understanding c. sitting behind the patient to decrease distractions d. standing near the patient's affected ear to balance sound

a. speaking clearly with distinct words

When caring for an elderly patient who presents with acute confusion of sudden onset, which test would the nurse expect to be ordered? a. urine culture and sensitivity testing b. Mini-Mental State Examination (MMSE) c. Swallow evaluation d. Magnetic resonance imaging (MRI) with contrast

a. urine culture and sensitivity testing

Presbyopia

age related farsightedness

A patient is admitted to the hospital for a scheduled cataract surgery. While assessing the patient, the nurse notes that the patient has a progressive hearing disorder and is visually impaired. Which possible effects could occur with this type of sensory deprivation? Select all that apply. a. Stroke b. Boredom c. Disorientation d. Malnourishment e. Poor task performance

b, c and e

Which activities may weaken hearing ability? Select all that apply. a. Yoga b. Woodworking c. Target shooting d. Listening to loud music e. Office work

b, c, and d

Which nursing interventions would be necessary in caring for a patient with cognitive alterations who is hospitalized? Select all that apply. a. apply wrist restraints for combativeness b. place a clock in room for orientation c. keep floor free of clutter for safety d. identify staff with each interaction e. play loud music for distraction

b, c, and d

Which factors are responsible for adult sensorineural hearing loss? Select all that apply. a. Malnutrition b. Persistent exposure to loud noises c. Adverse reaction to ototoxic drugs d. Decreased immunity e. Head injuries

b, c, and e

Which of the following are commonly associated with Meniere disease? Select all that apply. a. hypertension b. hearing loss c. vertigo d. dyspnea e. tinnitus f. persistent cough

b, c, and e

The nurse is performing a Mini-Mental State Examination (MMSE) of a patient. Which cognition deficits does this test identify? Select all that apply. a. Risk of epilepsy b. Cognitive orientation c. Risk of drug abuse d. Orientation status e. Language skills

b, d, and e

Which statement by the patient with vertigo lets the nurse know that the patient has understood the home-going instructions? a. "I will buy a visual signal for my smoke detectors b. "I will have grab bars installed in my bathtub" c. "I will change positions quickly to avoid vertigo" d. "I will get a home phone with amplified sound"

b. "I will have grab bars installed in my bathtub"

The patient is being discharged to home after being evaluated for Meniere disease and episodes of dizziness. Which one of the following statements alerts the nurse that further reinforcement is necessary for safety? a. "I'll be careful in the morning when I first get out of bed." b. "It will be good to get back to my job on the train." c. "I have a small bench that I can use when I'm taking a shower." d. "I'm going to be changing to brighter light bulbs in the hallways."

b. "It will be good to get back to my job on the train."

Which patient is most likely to experience sensory deprivation? a. A 79-year-old visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities b. A 14-year-old girl isolated in the hospital because of severe immune system suppression c. A 66-year-old hearing-impaired adult who lives in an assisted-living facility d. A 9-year-old boy who is deaf and uses sign language to communicate with his friends, family, and teachers

b. A 14-year-old girl isolated in the hospital because of severe immune system suppression

The nurse has completed the admission assessment for a patient admitted to the hospital's subacute care unit. Of the following nursing diagnoses identified by the nurse, which takes the highest priority? a. Isolation from social activity b. Potential for injury c. Inability to manage adjustment d. Ineffective verbal communication

b. Potential for injury

The nurse is working with older adult patients in an extended care facility. To enhance the patients' gustatory sense, the nurse should: a. mix foods together b. assist with oral hygiene c. make sure foods are extremely spicy d. provide foods of similar texture and consistency

b. assist with oral hygiene

For a patient with receptive aphasia (Wernicke aphasia), which one of the following nursing interventions is the most effective? a. Proving the patient with a letter chart to use to answer complex questions b. using a system of simple gestures to communicate c. speaking louder and slower d. obtaining a referral for a speech therapist

b. using a system of simple gestures to communicate

A 72-year-old patient with bilateral hearing loss wears a hearing aid in her left ear. Which approach best facilitates communication with her? a. Speak directly into the patient's left ear. b. Approach the patient from behind and speak frequently. c. Face the patient when speaking; speak slower and in a normal volume. d. Face the patient when speaking; use a louder-than-normal tone of voice.

c. Face the patient when speaking; speak slower and in a normal volume.

Which goal statement is appropriate for a patient with the nursing diagnosis of Acute Confusion? a. Patient will remember nurse's name. b. Nurse will remind patient of his/her name with each shift c. Patient will state name and date with each nursing encounter d. Nurse will remind patient of name and date with each nursing encounter

c. Patient will state name and date with each nursing encounter

With advancing age, which of the following physiological changes in sensory function occurs? a. decreased sensitivity to glare b. increased number of taste buds c. decreased sensitivity to pain d. difficulty discriminating vowel sounds

c. decreased sensitivity to pain

A visually impaired diabetic patient states that he has lost the call light. What is the next step the nurse should take? a. clip the call light closer to the patient b. tell the patient that the call light is clipped to the bed c. describe the call light location, and take the patient's hand and guide it to that location d. instruct the patient to verbally call for a staff member because "someone is always nearby"

c. describe the call light location, and take the patient's hand and guide it to that location

During a home safety assessment, the nurse identifies that there are a number of hazards present. Of the following hazards that are noted by the nurse, which one represents the greatest risk for this patient with diabetic peripheral neuropathy? a. cluttered walkways b. absence of smoke detectors c. improper water heater settings d. lack of bathroom grab bars

c. improper water heater settings

A home safety measure specific for a patient with diminished olfaction is the use of: a. extra lighting in the hallways b. amplified telephone receivers c. smoke detectors on all levels d. mild water heater temperatures

c. smoke detectors on all levels

The patient has experienced a cerebrovascular accident (CVA/stroke) with resultant expressive aphasia. The nurse promoted communication with this patient by: a. speaking loudly and slowly b. speaking to the patient on the unaffected side c. using a picture chart for the patient's responses d. using hand gestures to convey information to the patient

c. using a picture chart for the patient's responses

Anosmia

complete loss of sense of smell

Decussate

crossing over of sensory pathways

A patient has been on contact isolation for 4 days because of a gastrointestinal infection. Which nursing measures to reduce sensory deprivation would the nurse implement? Select all that apply. a. Arranging for him to have a roommate b. Turning off the lights and closing the room drapes c. Arranging for peacefulness and frequent rest periods d. Helping him to a chair or bringing flowers into the room e. Sitting down, speaking, touching, and listening to his feelings and perceptions

d and e

The nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which statement by the patient would indicate that additional teaching is needed? a. "I should decrease the thermostat on my hot-water heater to prevent scalding." b. "I should check the temperature of bath water with a thermometer." c. "I should wear gloves in winter." d. "I should use heat therapy to improve sensation."

d. "I should use heat therapy to improve sensation."

Which assessment strategy performed by the nurse helps determine the spatial perception of the patient? a. Engaging the patient in conversation b. Asking the patient to read from a book c. Having the patient add simple numbers d. Having the patient draw the face of a clock

d. Having the patient draw the face of a clock

A patient who has vision and hearing problems has a history of striking out at caregivers. Which nursing intervention would be most appropriate? a. Consulting the health care provider regarding use of restraints b. Performing tasks quickly to reduce risks to caregivers c. Explaining to the patient that this is unacceptable behavior d. Obtaining the patient's consent before starting care

d. Obtaining the patient's consent before starting care

The nurse is caring for an older patient with glaucoma. When developing a discharge plan, which priority intervention enables the patient to function safely with existing deficits? a. Encouraging the patient's family to visit him or her once a month b. Suggesting to the patient that he or she consider moving to a long-term care facility c. Saying nothing because it is important that the patient identify personal interventions to compensate for a sensory alteration d. Working closely with the patient to identify ways to modify his or her home environment and refer to appropriate community-based resources

d. Working closely with the patient to identify ways to modify his or her home environment and refer to appropriate community-based resources

The patient was working in the kitchen and was splashed in the face with a caustic cleaning agent. His eyes were affected and he was brought to the hospital for treatment. After cleansing and evaluation, his eyes were bandaged. When assisting this patient to eat, the nurse should: a. feed the patient the entire meal b. allow the patient to experiment with foods c. encourage the family to feed the patient d. orient that patient to the location of foods on the plate

d. orient that patient to the location of foods on the plate

Which recommendation in the home-going instructions is appropriate for a patient with damage to the chemoreceptors of the upper nasal passage? a. arranging for lighted signals on doorbells and telephones b. obtaining a thermometer for testing bath water temperature c. installing amplification devices on TVs, doorbells and telephones d. scheduling yearly safety checks of gas hot water heaters and furnaces

d. scheduling yearly safety checks of gas hot water heaters and furnaces

The nurse is caring for a patient with decreased sensation in the lower extremities. Which precaution does the nurse advise the patient to take? a. use heat to warm hands during cold weather b. go barefoot at home to prevent blisters from shoes c. soak feet in cold water daily to decrease swelling d. test the bath water temperature to prevent burning injuries

d. test the bath water temperature to prevent burning injuries

The nurse is working with a patient with a moderate hearing impairment. To promote communication with this patient, the nurse should: a. use a louder tone of voice than normal b. select a public area to have a conversation c. approach a patient quietly from behind before speaking d. use visual aids such as the hands and eyes when speaking

d. use visual aids such as the hands and eyes when speaking

Cognition

knowing influenced by awareness and judgment

Tactile

relating to the sense of touch