Foundations Chapter 43: PrepU
The student is studying the sensory experience. Which statement indicates that the student understands the four conditions that must be met for a client to experience the world? -"An agent, act, or other influence capable of initiating a response by the nervous system must be present." -"The brain must receive the stimulus and convert it to a nerve impulse." -"The nerve impulse is conducted along a nervous pathway from the brain to the receptor or sense organ." -"A particular area in the spinal cord must receive and translate the impulse into a sensation."
-"An agent, act, or other influence capable of initiating a response by the nervous system must be present." For a person to receive the necessary data to experience the world, four conditions must be met: a stimulus—an agent, act, or other influence capable of initiating a response by the nervous system—must be present; a receptor or sense organ must receive the stimulus and convert it to a nerve impulse; the nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain; and a particular area in the brain must receive and translate the impulse into a sensation.
While the nurse is assessing an older adult client, which statement by the client requires further investigation? -"I can only sleep when the lights are off." -"I need to go back to my room." -"What time is my ultrasound scheduled for?" -"When will my son come visit me?"
-"I need to go back to my room." The client expresses the need to return to their room but they have forgotten that they are in their room. This should alert the nurse of a mental status change. Mental status data, including level of consciousness, orientation, attention span, memory, and cognitive skills, can be collected during the client history. Telling the nurse that they can only sleep with lights off is appropriate. Asking when a test is scheduled or when the client's son will visit are normal questions.
The student is explaining the factors affecting sensory stimulation to his professor. The professor knows that which of the student's statements is most accurate? -"The amount of stimuli different people consider optimal is consistent from person to person." -"Adulthood tends to increase sensory functioning." -"Religious norms within a culture influence the amount of sensory stimulation a person seeks." -"Narcotics and sedatives increase awareness of sensory stimuli."
-"Religious norms within a culture influence the amount of sensory stimulation a person seeks." Ethnic norms, religious norms, income group norms, and the norms of subgroups within a culture all influence the amount of sensory stimulation a person seeks and perceives as meaningful. The amount of stimuli different people consider optimal appears to vary considerably. Sensory functioning tends to decline progressively throughout adulthood. Narcotics and sedatives decrease awareness of sensory stimuli.
The nursing instructor wants to evaluate the student's knowledge of sensory functioning. The instructor knows the student understands sensory reception when the student states which of the following? -"Visceral senses help the client sense movement and position of the body, usually at a subconcious level." -"Stereognosis is the sense that perceives the solidity of objects." -"Gustatory is the sense of smell." -"Sensory reception is the conscious process of selecting, organizing, and interpreting data from the senses."
-"Stereognosis is the sense that perceives the solidity of objects."
The nursing instructor wants to evaluate the student's knowledge of sensory functioning. The instructor knows the student understands sensory reception when the student states which of the following? -"Visceral senses help the client sense movement and position of the body, usually at a subconcious level." -"Stereognosis is the sense that perceives the solidity of objects." -"Gustatory is the sense of smell." -"Sensory reception is the conscious process of selecting, organizing, and interpreting data from the senses."
-"Stereognosis is the sense that perceives the solidity of objects." Stereognosis is the sense that perceives the solidity of objects and their size, shape and texture. Proprioception is the term used to describe the sense, usually at a subconscious level, of the movements and position of the body and especially its limbs. Gustatory is the sense of taste. Sensory perception is the conscious process of selecting, organizing, and interpreting data from the senses into meaningful information.
The nursing student is studying the reticular activating system (RAS). Which statement indicates to the professor that the student has mastered the information? -"The RAS is a well-defined network that extends from the hypothalamus to the medulla." -"The RAS allows all impulses to reach the cerebral cortex and to be perceived." -"The RAS serves to monitor and regulate incoming sensory stimuli." -"To receive stimuli and respond appropriately, the brain can be in any state of arousal."
-"The RAS serves to monitor and regulate incoming sensory stimuli." The RAS serves to monitor and to regulate incoming sensory stimuli. To receive stimuli and respond appropriately, the brain must be alert or aroused. The RAS, a poorly defined network, extends from the hypothalamus to the medulla. Nerve impulses from all the sensory tracts reach the RAS, which then selectively allows certain impulses to reach the cerebral cortex and to be perceived.
The neonatal intensive care unit (NICU) nurse is reviewing sensory development in the neonate. Which statement indicates to the preceptor that the nurse knows how to provide stimulation for these neonates? -"Medically fragile infants need constant light and visual stimulation." -"Rocking and changes of body position will help to stimulate visual sensations." -"Stimulation is not needed as the neural pathways are mature in the newborn." -"The use of mobiles will stimulate visual sensation."
-"The use of mobiles will stimulate visual sensation." Although the newborn is capable of rudimentary perceptual discrimination at birth, many neural pathways are immature and must be stimulated to be developed. The use of mobiles will stimulate visual sensations. Rocking and changes of body position will help to stimulate kinesthetic sensations. Medically fragile infants are recommended to have limited light; they should also have visual and vestibular stimulation to simulate being in the womb.
Which situation demonstrates sensory adaptation? -A client has learned to sleep through the frequent beeping of the intravenous pump. -A client with hearing loss has learned to communicate using sign language. -A client with vision loss has begun buying large-print books. -A client believes their hearing has become more acute since the loss of his vision.
-A client has learned to sleep through the frequent beeping of the intravenous pump. Adaptation occurs when the body adapts to constant stimuli, such as the continuous beeping of a hospital device. Adaptation is not the same as compensation. Compensation is when the client learns sign language for the hearing loss, and uses large print books for visual changes. A client believes their hearing has become more acute since the loss of his vision is an assessment of a personal change and not a nursing assessment.
Which client is most likely susceptible to the effects of disturbed sensory perception? -A client who is receiving care in the intensive care unit (ICU) for the treatment of septic shock -An older adult client whose lung disease is being treated in the acute care for elders (ACE) unit of the hospital -A client who has just been admitted to the emergency department with reports of chest pain -A client who is having cataract surgery in an outpatient eye clinic
-A client who is receiving care in the intensive care unit (ICU) for the treatment of septic shock Clients in critical care settings are particularly susceptible to severe sensory alterations. A client who has been in a setting for a short time, such as an emergency or day surgery setting, is less likely to experience disturbed sensory perception. Older adults are often vulnerable to sensory disturbances, but the risks posed by an ICU setting likely supersede a geriatric medical unit.
A client has newly diagnosed cirrhosis and has pulled his nasogastric (NG) tubing for the third time. His ammonia level is above normal. Which nursing diagnosis is appropriate for this client? -Alteration in Rest and Comfort -Disturbed Thought Process -Ineffective Impulse Control -Acute Confusion
-Acute Confusion Electrolyte imbalances, alterations in blood chemistry (e.g., elevated ammonia, elevated blood urea nitrogen), and toxic levels of drugs that affect the CNS can alter sensoristasis resulting in a nursing diagnosis of Acute Confusion. Alteration in rest and comfort would be a diagnosis of a client experiencing difficulty getting to sleep and staying asleep. Disturbed thought process would be a diagnosis for a client experiencing hallucination or delusions. Ineffective impulse control would be for a client experiencing attention deficit disorder or attention deficit hyperactivity disorder.
The nurse takes into consideration factors that affect sensory stimulation in hospitalized clients when planning care. Which statement is true? -Different personality types demand the same level of stimulation. -Decreased sensory stimulation may be sought during periods of low stress. -Illness does not affect the reception of sensory stimuli. -An individual's culture may dictate the amount of sensory stimulation considered normal.
-An individual's culture may dictate the amount of sensory stimulation considered normal. The amount and quality of stimuli necessary to produce overload may differ greatly from one person to another and is influenced by factors such as age, culture, personality, and lifestyle. Different levels of stimulation are required by people based on their personality. During periods of low stress increased sensory stimulation may be sought. Illness may make a person hypersensitive to sensory stimuli.
The nurse is teaching a group of clients about general eye care to prevent vision loss and eye injury. What will the nurse include in the presentation? Select all that apply. -Avoid eye damage from ultraviolet rays. -Use caution with corrosive agents. -Use a saline eye rinse daily. -Avoid eye strain and rubbing eyes. -Wear protective goggles for mowing lawns.
-Avoid eye damage from ultraviolet rays. -Use caution with corrosive agents. -Avoid eye strain and rubbing eyes. -Wear protective goggles for mowing lawns. The first priority is to teach clients self-care behaviors for maintaining vision and preventing blindness. These include: avoid rubbing eyes, avoid eye strain, avoid damage from ultraviolet rays, protect eyes from foreign bodies, keep eyeglasses clean, protected, and adjusted, avoid nonprescription eye drops and seek attention for symptoms, avoid cleaning eyes or contact lenses with soiled articles, use caution with aerosol sprays, and use caution with ammonia, lye, etc. Use of an eye rinse is only on advice of a physician.
For which conditions would the nurse assess to determine if a client is suffering from sensory deprivation or overload? Select all that apply. -Boredom -Decreased sleeping -Quickness of thought -Anxiety -Dreamless sleep -Thought disorganization
-Boredom -Anxiety -Thought disorganization When assessing for sensory deprivation or overload, the nurse should observe the client for boredom, inactivity, slowness of thought, daydreaming, increased sleeping, thought disorganization, anxiety, panic, delusions, and hallucinations.
The nurse is working with a student nurse on the surgical unit. The nurse should describe what benefit of providing health education before the procedure? -Clients are better able to handle new experiences. -Time is limited after the procedure because of the trend toward early discharge. -Client education is the nurse's professional responsibility. -Nurse practice acts dictate this specific practice.
-Clients are better able to handle new experiences.
The nurse is working with a student nurse on the surgical unit. The nurse should describe what benefit of providing health education before the procedure? -Clients are better able to handle new experiences. -Time is limited after the procedure because of the trend toward early discharge. -Client education is the nurse's professional responsibility. -Nurse practice acts dictate this specific practice.
-Clients are better able to handle new experiences. Education is a significant nursing responsibility that helps prepare clients for sensory experiences but not the only nurse can provide the information. An informed client is better able to handle fears, frustration, and confusion. Therefore, explain procedures before performing them or having the client experience them. Explanations also help prevent the client from feeling that his space and body are being invaded. The need for pre-procedure education is unrelated to early discharge. Education is a nursing responsibility, but the ultimate rationale is the direct benefit to the client. Nurse practice acts provide direction on nursing responsibility as identified by each state.
An older adult client who is in a long-term care facility tells the nurse, "I'm not eating that, it's poisoned." The nurse interprets this as which manifestation of altered sensory perception? -Hallucination -Delusion -Sensory deficit -Withdrawal
-Delusion The client is exhibiting delusional behavior. Delusions are beliefs not based in reality that reflect an unconscious need or fear. Hallucinations are sensory impressions, such as hearing voices, based on internal stimulation. Sensory deficit is impaired function in sensory reception or perception. Withdrawal is characterized by loss of interest in activities or interaction with others.
Which intervention when used by the nurse will help prevent sensory deprivation for clients in a long term facility? -The nurse must introduce herself to the client at the start of each shift. -The nurse should only speak with the client when she is facing the client. -Dress the client for the day's activities. -Leave television on the entire day.
-Dress the client for the day's activities.
Which intervention when used by the nurse will help prevent sensory deprivation for clients in a long term facility? -The nurse must introduce herself to the client at the start of each shift. -The nurse should only speak with the client when she is facing the client. -Dress the client for the day's activities. -Leave television on the entire day.
-Dress the client for the day's activities. Providing meaningful external stimuli can help a client overcome sensory deprivation or sensory deficit. Measures to provide stimulation include playing the television or the radio occasionally, playing music for brief periods, encouraging use of a clock and calendar, encouraging the client to dress for the day's activities, putting up colorful pictures, encouraging visitors, encouraging family to bring in personal items such as photographs, opening the drapes, and turning on lights. Place the bed or chair so the client can see or hear activities in the area and when someone enters the room. The nurse should orient the client each time to assist with memory recall and if necessary and the client has not difficulty with hearing, the nurse can talk when the client is turned.
The nurse is caring for Mr. Cantrell, a 69-year-old client. He has gradually lost much of the ability to hear in both ears due to working with loud machinery all of his working life. Which interventions will the nurse add to Mr. Cantrell's care plan in order to make him more comfortable with his hearing loss? Choose all that apply. -Avoid verbal conversation when possible. -Face the client; use meaningful gestures. -Be aware of nonverbal communication. -Decrease background noise if possible. -Do not chew gum or food when speaking.
-Face the client; use meaningful gestures. -Be aware of nonverbal communication. -Decrease background noise if possible. -Do not chew gum or food when speaking. When communicating with clients who have hearing deficits or impairments, the nurse should follow these guidelines: (1) Orient the person to the nurse's presence before initiating conversation. This may be done by moving so the nurse can be seen or by gently touching the person; (2) Decrease background noises (television, radio) if possible before speaking; (3) Make sure that hearing aids (if applicable) are working optimally; (4) Nurse should position herself so that the light is on her face and the person can see the nurse's lips and expressions; (5) Talk directly to the person while facing him, or angle the chair so that the nurse's voice reaches the ear that hears best. If the person is able to lip-read, use simple sentences and speak in a quiet, natural manner and pace; (6) Be aware of nonverbal communication; (7) Do not chew gum, cover mouth, or turn away when talking with the person; (8) Determine ideas to be expressed, as appropriate; and (9) Avoid verbal conversation, because it will heighten the client's feeling of isolation.
The nurse is caring for an older adult client that recently lost total vision in both eyes due to macular degeneration. Which interventions will the nurse add to the client's plan of care to assist with the with vision loss? Choose all that apply. -Hold tightly to the client's arm during ambulation. -Inform the client when the nurse is leaving the room -Acknowledge presence when entering the room. -Speak in a louder tone than usual. -Clear the room of clutter and do not rearrange furnishings. -Orient to sounds in the immediate environment.
-Inform the client when the nurse is leaving the room -Acknowledge presence when entering the room. -Clear the room of clutter and do not rearrange furnishings. -Orient to sounds in the immediate environment. When communicating with clients with reduced vision, the nurse should follow these guidelines: acknowledge presence in the client's room, identify oneself by name, speak in a normal tone of voice, remember that the blind person is unable to pick up most nonverbal cues during communication, explain the reason for touching the person before doing so, keep the call light or bell within easy reach of the person and place the bed in the lowest position, orient the person to sounds in the environment, orient the person to the arrangement of the room and its furnishings, clear pathways for the person and do not rearrange furnishings and clarify this fact with housekeeping personnel, assist with ambulation by walking slightly ahead of the person, allowing the person to grasp nurse's arm, stay in the person's field of vision if she has partial or reduced peripheral vision, provide diversions using other senses, and indicate to the person when the conversation has ended and leaving the room.
A neonatal intensive care nurse is caring for an infant born prematurely. How will the nurse manage the infant's environment to best support his sensory needs? -Limit lighting, visual, and vestibular stimulation. -Provide an active, stimulating environment. -Encourage frequent visitors and tactile stimulation at least hourly. -Provide changing patterns of light and shade, and the use of bright objects.
-Limit lighting, visual, and vestibular stimulation. To facilitate developmentally supportive care, it is recommended that medically fragile infants such as a premature infant should have limited light, visual, and vestibular stimulation to simulate being in the womb. The premature infant is not a full term infant and has developmental issues that are critical to their growth and development. Stimulation such as touch and frequent visitors is not recommended. The use of bright lights are contraindicated as the hospital environment should mimic the intrauterine environment which is quiet and dark.
The nurse is caring for Emily, an 81-year-old client who is struggling to adapt to worsening vision as she ages. The nurse performs which interventions to assist Emily in adapting to this sensory deficit? Choose all that apply. -Make sure her glasses are available. -Provide adequate lighting. -Provide large print books. -Orient to person, place, and time. -Speak so she can observe lip movements.
-Make sure her glasses are available. -Provide adequate lighting. -Provide large print books. Wearing her glasses, having adequate lighting, and having large print books are all strategies to assist a client with a visual deficit. Orientation to person, place, and time is not necessary because Emily is not disoriented. Emily does not have a hearing problem, so it is not necessary for her to observe lip movements.
A resident of a long-term care facility has moderate hearing loss. When communicating with this resident, what should the nurse do? -Minimize background noises and ensure that lighting is adequate to see the nurse's face. -Use written communication whenever possible in order to minimize the client's frustration. -Repeat each direction or question in different terms in order to maximize understanding. -Use vocabulary and concepts that are as simple and unambiguous as possible.
-Minimize background noises and ensure that lighting is adequate to see the nurse's face. When communicating with clients who have hearing loss, it is important for the nurse to minimize background noise and to position herself where there is enough light in order to facilitate lip reading. It would be unnecessary and inappropriate to exclusively use written communication with a client who has moderate hearing loss, or to repeat all questions and instructions in different terms. A hearing deficit is not synonymous with a cognitive deficit; consequently, it is not usually necessary to simplify concepts or vocabulary.
A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls? -Secure a restraint order from the physician. -Educate the client on the risk for falls. -Require a family member to be in the room at all times. -Monitor the client frequently.
-Monitor the client frequently. Individualized nurse-client interaction promotes sensory health function. Clients at risk for sensory deprivation may need frequent interaction initiated by the nurse, whereas others may not. In any case, provide appropriate stimuli, such as addressing the client by name, introducing and reintroducing yourself as necessary, explaining all activities, and when leaving, acknowledging when you will return. Family may not be available to assist with client at all times. With a sensory deprivation, the client may not understand the nurse's teaching about fall prevention. Restraints should be used if other less restrictive measures have been exhausted.
The nurse is caring for Nancy, a 45-year-old client with diabetes mellitus. She has severe neuropathy and consequently has little or no feeling in her feet and lower legs. The nurse includes which nursing interventions in the care plan related to this lack of tactile sensation? Select all that apply. -Perform frequent, thorough skin assessments. -Do not allow assistive devices to be used. -Assess for shoe type and correct fit. -Educate client to never go barefoot. -Protect skin from temperature extremes.
-Perform frequent, thorough skin assessments. -Assess for shoe type and correct fit. -Educate client to never go barefoot. -Protect skin from temperature extremes. For a client with a decreased sense of touch, do the following: protect the client's skin from temperature extremes; assess the extremities for breaks in the skin, blisters, drainage, or open wounds; and ensure the client is ambulating with assistive devices. Clients with diabetic neuropathy should wear shoes with a wide toe box, should not go barefoot, and should wear clean, white cotton socks.
The nurse is working at a pediatric clinic when Mrs. Karlilse comes in with her toddler and two preschoolers. She is distraught and tells the nurse she wants her children to just sit quietly and look at books or take naps. Instead, she says the children play noisily and scatter toys throughout the house. She indicates that she loves her children, but does not understand the need for the loud activities. To provide correct education, the nurse's best response about appropriate play for the children includes which of the following? Select all that apply. -Play is an outlet for physical and emotional energy. -Play develops social skills and self-insights. -Play hinders appropriate communication. -Play facilitates development of bullying tendencies. -Play assists in learning gender roles. -Play develops muscles and coordination.
-Play is an outlet for physical and emotional energy. -Play develops social skills and self-insights. -Play assists in learning gender roles. -Play develops muscles and coordination. For children, engaging in developmentally appropriate play will develop muscles and coordination, provide an outlet for surplus physical energy, develop communication skills, provide sources of learning, act as a stimulant to creativity, develop social skills, teach sex roles, provide an outlet for the release of emotional energy, and develop self-insights. Engaging in appropriate play for developmental age does not hinder acquisition of appropriate communication and does not facilitate development of bullying tendencies.
The nurse is caring for Jim, an 88-year-old nursing home resident who is suffering from sensory deprivation. He lives in a small room, has no visitors, and has few interests. The nurse performs which interventions to assist Jim in adapting to this sensory deficit? Select all that apply. -Provide interactions with children and pets. -Encourage Jim to attend exercise classes. -Ensure that Jim eats at a table with other residents. -Use low tones when talking to Jim. -Provide large print books and magazines
-Provide interactions with children and pets. -Encourage Jim to attend exercise classes. -Ensure that Jim eats at a table with other residents. Providing interaction with children, pets, and other residents will assist to decrease sensory deprivation for Jim. Use of low tones when speaking to him and providing large print books will not decrease sensory deprivation.
During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and she believes she is in a hotel. How should the nurse best respond to this client's disorientation? -Reorient the client to place and time. -Ask the client what she was doing in 1949 and what hotel she believes she is in. -Provide hints during conversation as to the correct year and place. -Thank the client for her responses and document her cognitive status.
-Reorient the client to place and time. It is appropriate to reorient clients who are confused. Doing so in an effective and empathic manner requires the astute implementation of nursing skills. Engaging more deeply with the client's incorrect responses does not reorient her. Attempting to reorient the client in a subtle and indirect manner is not likely to be effective. Documenting the client's response is necessary, but this should be followed up by reorientation.
A client in the intensive care unit becomes very cognizant of the nurse's touch. This is a function of which system? -General adaptation syndrome -Local adaptation syndrome -Reticular activating system -Peripheral nervous system
-Reticular activating system
The nurse is conducting a health history with an adolescent client. During the interview, the adolescent tells the nurse about reading with the television on in the background but gets distracted by the sound of his neighbor's dog. What does the nurse identifies is being involved? -Reticular activating system -Nerve endings in the skin -Auditory receptors -Cerebral cortex
-Reticular activating system
A cycling accident has resulted in a head injury to a client with resultant ncreased intracranial pressure. Consequently, the client has been placed in a private room with low light and care has been organized to minimize disturbances. What situation is the client most likely at risk for? -Sensory Deprivation -Sensory Overload -Chronic Confusion -Acute Confusion
-Sensory Deprivation A care environment that is deliberately organized to minimize stimulation can create a risk of sensory deprivation. A client with a head injury should have a reduced sensory environment to keep intracranial pressure lower and decrease potential complications. Confusion, acute or chronic, are considered complications related to increased intracranial pressure and changes in oxygenation.
A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the client experiencing? -Physical -Psychological -Sensory deficits -Sociocultural
-Sensory deficits Sensory deficits in vision and hearing interfere with one's ability to interact with other people and with the environment.
A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness? -Somnolence -Coma -Stupor -Asleep
-Somnolence When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. A person in a coma cannot be aroused and does not respond to stimuli. Someone who somnolent is extremely drowsy, but will respond normally to stimuli.
A client who hallucinates simply to maintain an optimal level of arousal is experiencing: -sensory overload. -sensory deprivation. -cultural care deprivation. -sleep deprivation.
-sensory deprivation. Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. With decreased sensory input, the reticular activating system (RAS) is no longer able to project a normal level of activation to the brain. As a result, the person may hallucinate simply to maintain an optimal level of arousal. Sensory overload refers to too much stimulus. Cultural care deprivation refers to lacking care that is specific to cultural needs. Sleep deprivation is lack of necessary sleep.
Which actions are performed according to guidelines for caring for visually impaired clients? Select all that apply. -Wait for the person to sense your presence in the room before identifying yourself. -Speak in a normal tone of voice. -Orient the person to the arrangement of the room and its furnishings. -Assist with ambulation by walking slightly behind the person. -Sit in the person's field of vision if he or she has partial or reduced peripheral vision. -Explain the reason for touching the person after doing so.
-Speak in a normal tone of voice. -Orient the person to the arrangement of the room and its furnishings. -Sit in the person's field of vision if he or she has partial or reduced peripheral vision. When caring for a visually impaired client, nursing guidelines for care include speaking in a normal tone of voice. Some people speak loudly at clients with any sensory impairment, which is inappropriate. Orienting the client to the room and furnishings decreases the changes of client injury. Sitting in the client's field of vision increases the client's view of the nurse if the client's peripheral vision is reduced. The nurse should announce his or her presence when entering a visually impaired client's room. Explanation of touch should be given prior to touching the client. When assisting with ambulation of a visually impaired client, the nurse should assist by walking slightly ahead of the person, allowing the person to grasp the nurse's arm.
The nurse is assisting a client who is visually impaired and has right-sided weakness. Which steps are accurate? Select all that apply. -Stand on the client's right side. -Stand on the client's left side. -The nurse should be 2 feet (0.61 m) in front of the client. -The nurse should be 1 foot (0.3 m) in front of the client. -Have the client grasp the nurse's arm.
-Stand on the client's right side. -The nurse should be 1 foot (0.3 m) in front of the client. -Have the client grasp the nurse's arm.
The nurse is assisting a client who is visually impaired and has right-sided weakness. Which steps are accurate? Select all that apply. -Stand on the client's right side. -Stand on the client's left side. -The nurse should be 2 feet (0.61 m) in front of the client. -The nurse should be 1 foot (0.3 m) in front of the client. -Have the client grasp the nurse's arm.
-Stand on the client's right side. -The nurse should be 1 foot (0.3 m) in front of the client. -Have the client grasp the nurse's arm. When assisting a visually impaired client with ambulation, stand on the client's nondominant side, about 1 foot (0.3 m) in front of him. Have the client grasp your arm with the nondominant hand and use the dominant hand to feel around for barriers or landmarks. Always maintain an uncluttered environment. The client cannot use the right hand to feel for barriers; therefore, the nurse should have the client on their right side using the left hand to feel around.
While assessing a patient's neurological status, Janet Wilkes, RN, asks the patient to close his eyes and identify the object Janet places in his hand (a pencil). Janet explains that this lets her know if the patient is able to identity the solidity, size, shape, and texture of the object. Janet documents this as which of the following? -Proprioception -Stereognosis -Kinesthesia -Sensory perception
-Stereognosis Stereognosis is the sense that perceives the solidity of objects and their size, shape, and texture. Proprioception is the term used to describe the sense, usually at a subconscious level, of the movements and position of the body and especially its limbs, independent of vision. Kinesthesia refers to awareness of positioning of body parts and body movement. Sensory perception is the conscious process of selecting, organizing, and interpreting data from the senses into meaningful information.
The nurse is caring for a client who sustained a traumatic brain injury in a skiing accident. The client is breathing idenpendantly, drowsy, but arousable with extreme or repeated stimuli. How will the nurse document the client's level of consiousness? -Somnolence -Coma -Stupor -Asleep
-Stupor When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. A person in a coma cannot be aroused and does not respond to stimuli. Someone who somnolent is extremely drowsy, but will respond normally to stimuli.
A client has expressed great relief at the improvement in their hearing after irrigation of the ear canal yielded a large amount of impacted cerumen. This client was experiencing a sensory alteration related to: -sensory reception. -sensory perception. -sensory transmission. -sensory reaction.
-sensory reception.
The nurse is creating a care plan for the legally blind client who is confused and easily agitated. Which priority outcome is appropriate for this client? -The client will stay in bed at all times. -The client will learn how to communicate needs. -The client will remain safe. -The client will consistently follow instructions.
-The client will remain safe. Client goals are individualized but focus on achieving optimal sensory function. A nursing diagnosis for the client is Disturbed Sensory Perception. The priority goals for this client is ensuring the client remains safe. Developing an effective communication mechanism is a secondary goal. If the client is confused, he or she may or may not be able to communicate needs or follow instruction. A client may have toileting needs that may make it difficult to remain in the bed at all times. In this care, the nurse cannot assume that this intervention is appropriate.
A client in the intensive care unit will be less likely to experience sensory overload in which situation? -A clock displays date, time, and AM/PM. -The nurse silences electronic equipment when safe to do so. -The nurse provides touch every hour. -The family visits as frequently as possible.
-The nurse silences electronic equipment when safe to do so. Minimizing unnecessary noises can prevent sensory overload in clients. Disorientation can occur when expected day/night differences in levels of general activity are lost. To reduce such disorientation, provide a clock displaying a clear distinction of AM/PM time, day, and date. Touch and frequent visits may exacerbate sensory overload.
The nurse is caring for Mrs. Meld, a 62-year-old client with dementia who is confused. Which nursing interventions will the nurse include in Mrs. Meld's care plan to facilitate communication? Choose all that apply. -Use frequent face-to-face contact. -Reorient the client to her environment as needed. -Speak calmly, simply, and directly. -Use clocks and calendars for orientation. -Answer questions in as much detail as possible.
-Use frequent face-to-face contact. -Reorient the client to her environment as needed. -Speak calmly, simply, and directly. -Use clocks and calendars for orientation. Nursing interventions for the confused client include the following: use frequent face-to-face contact to communicate the social process (use touch when appropriate, walk arm in arm, hug, give a backrub), speak calmly, simply, and directly to the client and allow sufficient time for the client to think before responding, orient and reorient the client to the environment and fill the client's personal space with as many personal objects as possible, and use conversation, watches, clocks, calendar, newspaper, television, radio, and other such devices to orient the client to time, place, and person. Using lots of detail may cause additional confusion and hinder communication.
Sensory function begins with the reception of stimuli by the senses. Which are special senses? Select all that apply. -Visual -Visceral -Gustatory -Kinesthetic -Auditory
-Visual -Gustatory -Auditory Visual (sight), gustatory (taste), auditory (hearing), olfactory (smell), and tactile (touch) sensations are special senses. Their respective receptor organs are the eyes, taste buds of the tongue, the ears, the nose, and nerve endings in the skin. Kinesthetic and visceral sensations are somatic senses. Their receptors are nerve endings in the skin and body tissues.
A nursing instructor is preparing a class presentation about sensory perception across the lifespan. At which developmental stage would the instructor describe sensory perception as at its peak? -Preschooler -Adolescent -Young adult -Older adult
-Young adult A young adult's sensory perception function is at its peak. However, as people reach middle age, they begin to notice certain changes in their sensory system. Eyesight diminishes, sounds become more muffled, and the other sensory systems deteriorate. Preschoolers are in the process of building their sensory perception skills by investigating and learning about the environment. Sensory perception in an adolescent is still in the process of development. At this developmental stage, adolescents are learning to make independent responses based on what is perceived through the senses. As people reach older adulthood, sensory systems deteriorate and sensory perception is weak.
The nurse is working on a neurological unit and a physician asks the nurse to perform a sensory experience assessment for a client. The nurse thinks about what things may place a person at risk for disturbed sensory perception and comes up with which of the following? Select all that apply. -diminished senses related to advanced age -wearing corrective eyeglasses for poor vision -neuropathy related to diabetes mellitus -medications that alter certain senses -wearing a hearing aid for diminished hearing
-diminished senses related to advanced age -neuropathy related to diabetes mellitus -medications that alter certain senses Aging is often accompanied by diminished senses. Diseases can diminish senses. Diabetes-related neuropathies can result in a loss of sensation in the limbs, rendering the client with diabetes unable to feel hot objects such as bath water, which can result in burns. Certain drugs affect taste. Wearing corrective devices, such as eyeglasses and hearing aids, does not put anyone at risk for disturbed sensory perception.
The nurse is assessing a group of assigned clients. Which client's does the nurse determine are more sensitive to sensory alterations? Select all that apply. -a 75-year-old male admitted to the hospital for urinary tract infection -a 65-year-old client staying in an assisted living community -a 75-year-old client taking narcotic pain medication for a fractured hip -a 50-year-old client who works in a baseball stadium -a 65-year-old client who serve in the Vietnam War and is living alone
-a 75-year-old male admitted to the hospital for urinary tract infection -a 75-year-old client taking narcotic pain medication for a fractured hip -a 50-year-old client who works in a baseball stadium -a 65-year-old client who serve in the Vietnam War and is living alone Sensory stimuli in the environment affect sensory perception. Previous experience affects sensory perception in that people become more alert to stimuli that evoke a strong response. Lifestyle affects sensory perception. One person may enjoy a lifestyle of abundant stimulation, surrounded by many people, frequent changes, bright lights, and noise. Those with a traumatic military background may have been surrounded by loud noises which are difficult to overcome in civilian life. Another example is the client who works in a baseball stadium where large crowds yell and there is a variety of stimuli. Central nervous system depressants, such as opioid analgesics, decrease awareness and impair perception of stimuli. A client with a UTI may exhibit confusion related to the infection and combined with a busy health care facility, the over stimulation may affect sensory perception and overwhelm the client. A client who lives in an assisted living facility is not overwhelmed with sensory stimuli and may be able to have time to relax without any interaction during quiet periods.
Which client is experiencing a disturbance in sensory perception as the primary problem, rather than the etiology of another problem? -a client who is experiencing acute confusion as a result of a drug interaction -a client who is experiencing sleep disturbances as a result of sensory deprivation -a client who is experiencing powerlessness as a result of his inability to interact with his environment -a client who is exhibiting ineffective coping related to sensory overload.
-a client who is experiencing acute confusion as a result of a drug interaction Acute confusion is a nursing diagnosis that is a direct example of a disturbance in sensory perception. Sleep disturbances can impact sensory perception but it is not a direct example. The feeling of powerlessness and ineffective coping are alterations in sensory perception.
For which conditions would the nurse assess a client to determine the ability to adequately receive the data necessary to experience the world? Select all that apply. -a response -a stimulus -a receptor or sense organ -an arousal mechanism -an intact nerve pathway -a functioning brain
-a stimulus -a receptor or sense organ -an intact nerve pathway -a functioning brain For a person to receive the necessary data to experience the world, four conditions must be met: · A stimulus—an agent, act, or other influence capable of initiating a response by the nervous system—must be present. · A receptor or sense organ must receive the stimulus and convert it to a nerve impulse. · The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. · A particular area in the brain must receive and translate the impulse into a sensation. A response and an arousal mechanism are not included in these conditions.
The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulus of a continuing noise often goes unnoticed. The ICU nurse explains that this phenomenon is known as: -adaptation. -sensoristasis. -cortical arousal. -sensory overload.
-adaptation. The body quickly adapts to constant stimuli. The repeated stimulus of a continuing noise, such as a low-level cardiac alarm, eventually goes unnoticed. A stimulus must be variable or irregular to evoke a response. This phenomenon is termed adaptation. Sensoristasis is the optimal arousal state of the reticular activating system. Cortical arousal refers to the different states of arousal or awareness. Sensory overload is the condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli.
The nurse is meeting an older adult client for the first time in their hospital room. Which of the following interventions should be a priority at this time? -showing the client how to turn the television on -demonstrating the correct use of the bedside commode -instructing the client not to pull his IV tubing out -asking if the client uses prescription glasses.
-asking if the client uses prescription glasses. Assessment of sensory function and risk factors for sensory alterations is necessary for all clients, especially when the alteration is a new or temporary one. Older adults require close assessment because they experience age-related sensory changes and subsequent underlying visual and hearing impairments. Instructing the client to not pull out their IV site is not appropriate as the older adult client does not have cognitive changes. Showing the client how to turn on the TV and the correct use of the bedside commode is important after assessments have been completed. The client may not need the instruction.
A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as well as techniques to follow when working with clients with hearing impairments. An appropriate nursing intervention discussed by the instructor includes: -demonstrating or pantomiming ideas to clients with hearing impairments. -cleaning the clients' ears daily with a cotton-tipped applicator. -speaking loudly and directly to clients with hearing impairments. -encouraging clients to use earphones adjusted to a loud volume for hearing.
-demonstrating or pantomiming ideas to clients with hearing impairments. For hearing-impaired clients, demonstrating or pantomiming may assist in communication. Clients should be instructed to avoid cleaning the ear with cotton-tipped applicators or sharp objects as this can cause damage to the inner ear. While speaking directly may enhance communication, speaking loudly will not benefit the client. Clients should be discouraged from using earphones that concentrate loud noise in the ear canal causing acoustic damage.
A client who hallucinates simply to maintain an optimal level of arousal is experiencing: -sensory overload. -sensory deprivation. -cultural care deprivation. -sleep deprivation.
-sensory deprivation.
The nurse is conducting health education with a group of older adults in the clinic. Which activity should the nurse include in the education that can prevent sensory loss in the older adult population? -Schedule eye examinations every 4 years. -good management of illness such as hypertension -Continue driving a car to maintain memory skills. -Avoid places full of people to prevent spread of infection.
-good management of illness such as hypertension Client education to promote sensory health and function focuses on ways to prevent sensory loss and to maintain general health. Education topics include the importance of frequent eye examinations (yearly) and close control of chronic illnesses such as hypertension and diabetes. Age related changes in eyesight and motor function may affect the ability to drive. Avoiding places full of people can prevent infection but may cause sensory overload in the elderly.
After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment? -having a caregiver in the home for the first few days after surgery -removing all furnishings to eliminate any obstruction -The client should be admitted to the hospital after this surgery. -Keep the house dimly lit at all times to avoid sensory overload
-having a caregiver in the home for the first few days after surgery
After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment? -having a caregiver in the home for the first few days after surgery -removing all furnishings to eliminate any obstruction -The client should be admitted to the hospital after this surgery. -Keep the house dimly lit at all times to avoid sensory overload
-having a caregiver in the home for the first few days after surgery With rising costs and shorter hospital stays, a client may be discharged while still adjusting to his condition. This can be a new or worsening sensory deficit, or an illness or treatment that causes sensory deprivation or sensory overload. Initiate planning as soon as possible to help the client adjust to sensory dysfunction. The nurse should encourage enlisting the help and cooperation of family and friends, education, assembling sensory aids and equipment, contacting home health services, and locating additional support groups as needed. With the assistance of a family or friend, the client does not need to remove the furnishings. After surgery, the client is not admitted to the hospital. Keeping the house dimly light is a risk for a fall as the client is experiencing a visual deprivation.
When admitting a wheelchair-bound client with paraplegia to the hospital, the nurse assesses the client for injuries. What injuries should the nurse assess the client for that may occur? -injuries that occur from sensory alteration -injuries that occur from sensory overload -Injuries that occur from gustatory senses -injuries that occur from progression.
-injuries that occur from sensory alteration Altered sensory reception occurs in such conditions as spinal cord injury, brain damage, changes in receptor organs, sleep deprivation, and chronic illness.
An intensive care unit nurse does not notice the noise within her environment. However, the client's family member states, "How can you stand it in here? The lights, sounds, and activity would drive me crazy and I couldn't take it." The nurse has adapted to her: -intensive care unit work. -intensive care unit environment. -threatening stimuli. -nursing career.
-intensive care unit environment. Sensory stimulation in the environment affects sensory perception. After routine exposure to stimulation, the body adapts.
Which nursing interventions support the older adult client's sensory needs while admitted in the hospital? -staying in the client's room as much as the nurse can -keeping the room well lighted -using touch therapy when communicating -including education into all nursing care activities
-keeping the room well lighted Preventing sensory dysfunction enables clients to interact with the environment optimally. Keeping the room well lighted allows for better visualization of the environment and allows the client to have better visualization of their surroundings. The nurse is not going to be able to stay with the elderly client as they have other clients to care for. Using touch therapy is appropriate for culturally sensitive care. Education should not be included in all nursing care activities and should be relevant based on the assessment needs of the client.
A nurse in the emergency room is assessing a client for sensory perception dysfunction. Which assessment techniques will the nurse use to gather objective data? Select all that apply. -observation -physical assessment -risk identification -diagnostic tests and procedures -normal pattern identification
-observation -physical assessment -diagnostic tests and procedures Objective data to assess a client's sensory perception function is collected by observation, physical assessment, and diagnostic tests and procedures. The nurse first observes the client to detect sensory function impairment. During physical assessment, the nurse performs simple tests to check for impairment of the senses. Diagnostic tests and procedures are performed to evaluate the level of sensory perception function and to determine the cause of sensory deficit. Risk identification, normal pattern identification, and dysfunction identification are methods of gathering subjective data for client assessment.
A hospital client has been awakened at night by the alarm on his roommate's intravenous pump. This client was aroused by brain action in his: -reticular activating system (RAS). -limbic system. -cerebellum. -prefrontal cortex
-reticular activating system (RAS). The RAS is the network that mediates arousal. The limbic system is a complex system of nerves and networks in the brain, involving several areas near the edge of the cortex concerned with instinct and mood. It controls the basic emotions (fear, pleasure, anger) and drives (hunger, sex, dominance, care of offspring). Cerebellum is the part of the brain that coordinates and regulates muscular activity. The prefrontal cortex is a part of the brain located at the front of the frontal lobe and is involved in a variety of complex behaviors and personality development.
A client who has awakened from a coma after a car accident and states, I knew about a news story reported during the time I was in the coma." What does the nurse identify is occuring with the client? -reticular activating system's stimulation. -sleep latency phase of sleep-wake cycle. -circadian rhythm for 24 hours. -sensory perception in a conscious process.
-reticular activating system's stimulation. Destruction of the reticular activating system produces coma and an electroencephalograph pattern consistent with sleep. When the nervous system is oriented to a stimulus and receptive toward it, the neurons of the RAS arouse the brain, facilitating information reception (Widmaier, Raff, & Strang, 2008). The RAS is highly selective.
A client has expressed great relief at the improvement in their hearing after irrigation of the ear canal yielded a large amount of impacted cerumen. This client was experiencing a sensory alteration related to: -sensory reception. -sensory perception. -sensory transmission. -sensory reaction.
-sensory reception. Impacted cerumen is an example of a sensory disturbance that is rooted in interference with the client's reception of stimuli. In this case, sound is unable to stimulate the organs of hearing and the client does not have a deficit in the perception, transmission, or reaction to sound. Sensory perception of pain would come from temperature, mechanical, electrical or chemical stimuli. Sensory transmission occurs by a nerve that passes impulses from receptors toward or to the central nervous system through the afferent nerve and the dorsal root that passes dorsally to the spinal cord and that consists of sensory fibers. A sensory reaction is the reaction time during which the subject's attention is directed to the stimulus rather than the response.
Which example indicates the use of an internal sensory receptor? -hearing loud music -spitting out of hot coffee -very bright light -eating sour candies
-spitting out of hot coffee Sensory function begins with reception of stimuli by the senses. An example is the spitting out of the mouth hot coffee. Eating sour candies may elicit a facial grimace or not. Hearing loud music may elicit the client to hold their ears. Very bright light may elicit the client to shield their eyes with their hands. Externally, stimuli are visual (sight), auditory (hearing), olfactory (smell), gustatory (taste), and tactile (touch). Their respective receptor organs are the eyes, ears, olfactory receptors in the nose, taste buds of the tongue, and nerve endings in the skin. The response is how the body reacts to the stimuli. Internally, the kinesthetic and visceral senses receive stimuli. Their receptors are nerve endings in the skin and body tissues. The kinesthetic sense influences awareness of the placement and action of body parts.
The nurse is working on a neurological unit and must perform an assessment on a client for disturbed sensory perceptions. The nurse thinks about the human senses and knows that they must assess for which of the following? Select all that apply. -use of assistive devices for senses -history of recent immunizations -medications that may alter sensations -anything interfering with sensory reception -any recent changes in sensory stimulation
-use of assistive devices for senses -medications that may alter sensations -anything interfering with sensory reception -any recent changes in sensory stimulation When performing an assessment for disturbed sensory perceptions, it is important to assess for anything interfering with sensory reception, such as decreased hearing, vision, or tactile sensation. Ask about any recent changes in sensory stimulation, such as death of a spouse who provided conversation, companionship, and touching. Medications, such as captopril, can cause taste alteration. Also, ask about what assistive devices are currently used, such as eyeglasses or hearing aids. Immunizations are not related to disturbed sensory perceptions.
The nurse is caring for Jim, an 88-year-old nursing home resident who is suffering from sensory deprivation. He lives in a small room, has no visitors, and has few interests. The nurse performs which interventions to assist Jim in adapting to this sensory deficit? Select all that apply. -Provide interactions with children and pets. -Encourage Jim to attend exercise classes. -Ensure that Jim eats at a table with other residents. -Use low tones when talking to Jim. -Provide large print books and magazines.
Provide interactions with children and pets. Encourage Jim to attend exercise classes. Ensure that Jim eats at a table with other residents. Providing interaction with children, pets, and other residents will assist to decrease sensory deprivation for Jim. Use of low tones when speaking to him and providing large print books will not decrease sensory deprivation.