EAQ Sensory Perceptions

A nurse uses the Braden Scale to predict a client's risk for developing pressure ulcers. Which data should the nurse use to determine a client's score on this scale?

Anorexia (nutrition) Hemiplegia (mobility/activity) History of diabetes (neuropathy) Urinary incontinence (moisture)

What response from the nurse demonstrates an understanding of hallucinating behavior by a client?

Asking "What are the voices telling you to do?" Hallucinations involve false perceptions of sensory stimuli that may be visual, auditory, tactile, or olfactory. Hearing voices is common with hallucination and appropriate for the nurse to clarify what the client is hearing. Illusion - mistaking stuffed animal for a real animal IE: a stuffed rat for a real rat Paranoia - Unfounded distrust IE: beliefs of poisoned food Psychotic - delirium that occurs in the evening or nighttime IE: Sundowning

A client is admitted to the hospital with a suspected brain tumor. Based on the history of loss of equilibrium and coordination, where does the nurse suspect the tumor is located?

Cerebellum The cerebellum is incolved in synergistic control of skeletal muscles and the coordination of voluntary movement.

A nurse is evaluating sensory changes in a client whose spinal cord was severed at the level of T6 and T7. What does this evaluation process require?

Client stating where the pinching sensation is felt. Squeezing the nurse's hand will not elicit what the client feels, it determines motor function. Changes in skin color are responses to heat or cold not pain.

Which cranial nerve damage may lead to a decrease in the client's olfactory acuity?

Cranial nerve I Cranial nerve I, also known as the olfactory nerve, originates at the olfactory bulb and assists with the perception of smell. Damage to this nerve may cause a decrease in olfactory acuity.

While assessing a client recovering from a head injury, the nurse notices a loss of movement in the client's tongue while attempting to talk. Which could be the possible reason for the client's condition?

Damage to the hypoglossal nerve Damage to the nerve that supplies the skeletal muscles of the tongue may lead to the loss of its ability to move. These muscles are supplied by the hypoglossal nerve (cranial nerve XII), which assists with motor functions of the tongue such as talking.

A nurse assesses a client who is suspected of being in myasthenic crisis. Which assessment is MOST definitive in support of this conclusion?

Difficulty breathing

A client with vascular dementia has signs and symptoms that are different from dementia of the Alzheimer type. What characteristics unique to vasular dementia should the nurse expect when assessing a client with this diagnosis?

Exaggerated deep tendon reflexes Episodic progression of symptoms Also - extensor plantar response, gait abnormalities, muscle weakness.

A 7-year old child with cerebral palsy who wears leg braces has a slight sensory loss in the lower extremities. What is the most essential information for the nurse to teach the child and parents?

Examine the skin for evidence of pressure points. When sensory perception is impaired, the resultant lack of effective specific motor responses, the child will be more vulnerable to skin irritation an trauma. Skin must be assessed daily when there is sensory loss.

A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. What impact does this disability have on their education?

Experience perceptual difficulties that interfere with learning ADHD interferes with the ability to perceive and respond to sensory stimuli, resulting in a deficit in interpreting new sensory data.

The school nurse knows that many children with attention deficit problems are also learning disabled. What should the nurse teach the parents about children with learning deficits?

Experience perceptual difficulties that make learning problematic.

After a left cataract extraction, a client reports severe discomfort in the operated eye. The nurse concludes that this problem may be caused by which condition? 1 Hemorrhage into the eye 2 Expected postoperative discomfort 3 Isolation related to sensory deprivation 4 Pressure on the eye from the protective shield

Hemorrhage into the eye

A client tells the nurse, "That man on the television is talking only to me." What should the nurse document that the client is exhibiting?

Idea of reference Also called a delusion of reference. It's a false personal belief that public events and people are connected directly to the client.

A nurse is caring for a client who just has had surgery on the ear. The nurse should assess for which early indicator of potential damage to the motor branch of the facial nerve?

Inability to wrinkle the forehead The motor fibers of the facial nerve innervate the superficial muscles of the face and scalp, allowing facial movement such as wrinkling the forehead.

A client has a history of diabetes mellitus. After assessing the client, the primary healthcare provider confirms damage to the sensory limb of the bladder spinal reflex arc. Which clinical manifestations could confirm this condition?

Infrequent voiding of large residual volumes Damage to the sensory limb of the bladder spinal reflex arc is a type of sensory neurogenic bladder where the client lacks the sensation of needing to urinate. This is seen in clients with multiple sclerosis and diabeted mellitus.

The caretaker of a client who sustained a head injury reports to the nurse that the client always says that food tastes unappealingly bland even though the food is good. Which area of the brain may the nurse suspect to be affect in the client?

Parietal Lobe Parietal lobe includes the interpretation of taste impulses and spatial perception and understanding of sensory inputs. Injury leads to loss of taste perception.

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele located at the fourth lumbar vertebra (L4). What is the priority nursing intervention while the infant is awaiting surgery?

Providing meticulous skin care Skin care is essential to prevent rupture of the sac and subsequent infection. There is no need to increase nutrition since no info of infant being malnourished. Exercises might be implemented AFTER the surgery.

After several interactions with a client, the nurse at the mental health clinic identifies a pattern of withdrawal and nonparticipation in situations requiring communication with others. In which area should the nurse expect the client to have difficulty? 1. Personal identity 2. Social interaction 3. Sensory perception 4. Verbal communication

Social Interaction Characteristics of clients with problems with social interaction include avoidance of others, problematic patterns of interaction and an inability to establish or maintain stable supportive relationships.

While assessing a client who sustained a road traffic accident, a nurse notices that the client is unable to clench his teeth. Which cranial nerve might have been affected?

Trigeminal nerve Trigeminal nerve provides sensory innervation to the facial skin and motor innervation to the muscles of the jaw. If this nerve is damaged, they will be unable to clench their teeth. Facial - sensory and motor innervations to facial expressions. Trochlear - downward and inward eye movements Abducens - eyeball's lateral movement