Fund Ch 49 Sensory Alterations
Sensory Alterations Quiz
Test your knowledge on sensory alterations with this comprehensive quiz designed for healthcare professionals and students alike! With 30 challenging questions, this quiz covers a wide range of topics related to sensory impairments and their implications on patient care.
Key Features:
- Explore various sensory deficits
- Understand assessment techniques
- Enhance your clinical knowledge
A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, “Ow, that was sharp!” What conclusion about the child will the nurse come to when interpreting the child’s response?
Sensations are intact
Reception is intact.
Perception is intact
Reaction is intact.
A nurse is describing the transmission of sound to a patient. In which order will the nurse list the pathway of sound, beginning with the first structure? 1. Eardrum 2. Perilymph 3. Oval window 4. Bony ossicles 5. Eighth cranial nerve
1, 5, 2, 4, 3
1, 3, 4, 2, 5
1, 2, 4, 5, 3
1, 4, 3, 2, 5
A nurse is caring for a patient diagnosed with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?
The patient frequently cleans out eyes with saline washes.
The patient applies different spices during mealtime to food.
The patient turns one ear toward the nurse during conversation.
The patient isolates self from social situations with groups of people.
The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit?
Xerostomia
Dysequilibrium
Diabetic retinopathy
Peripheral neuropathy
A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?
Impaired night vision
Difficulty hearing low pitch
Heightened sense of smell
Increased taste discrimination
A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse “Should I stop driving?” Which response by the nurse is most therapeutic?
Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk.”
Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can’t avoid an accident.”
No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go.”
No, instead you should see your ophthalmologist and get some glasses to help you see better.”
A patient who recently had a stroke is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient’s plan of care?
Teach the patient about special assistive devices.
Make the patient talk as much as possible
Obtain an order for antidepressant medications
Place a consult for a home health nurse.
A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan?
Risk for falls
Self-care deficit
Impaired socialization
Impaired physical mobility
During an assessment, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further?
Neurological deficit
Visual deficit
Hearing deficit
Balance deficit
A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected?
Perceptual
Cognitive
Affective
Social
Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient’s self-care ability?
Have you stopped reading books or switched to books on audiotape?”
What do you do to protect yourself from injury at work?”
Are you able to prepare a meal or write a check?”
How does your vision impairment make you feel?”
A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?
Administer a Mini-Mental State Examination (MMSE).
Ask the patient to state name, location, and what month it is.
Ask the patient’s family if the patient is behaving normally.
Administer the hearing handicap inventory for the elderly (HHIE-S).
Which patient is demonstrating a refractive error sensory problem?
A patient who frequently reports the incorrect time from the clock across the room.
A patient who is having difficulty remembering how to perform familiar tasks.
A patient who turns the television up as loud as possible.
A patient who has trouble saying words.
A nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse will be most appropriate for this patient?
Rinse your mouth several times a day to hydrate your taste buds.”
Avoid adding spices or lemon juice to food to prevent nausea.”
Blend foods together in interesting flavor combinations.”
Eat soft foods that are easy to chew and swallow.”
The nurse is creating a plan of care for a patient diagnosed with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit?
Body image disturbance
Impaired socialization
Risk for falls
Fear
The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift?
Expressive
Receptive
Global
Motor
The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?
Speaking with hands, face, and expressions
Using a loud voice, enunciating every syllable
Having direct conversation with the patient in the affected ear
Repeating the phrase again, if the patient does not understand what the nurse said
The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning?
Asks the nurse to test the temperature of the water before entering the bath.
Places colored stickers on faucet handles to indicate temperature.
Replaces all lace-up shoes with Velcro straps for ease.
Uses a heating pad on a low setting to keep warm.
A nurse is working to prevent blindness. Which preventive action is a priority?
Screen young adults early for visual impairments.
Include rubella and syphilis screening in the preconception care plan.
Instruct parents to report reduced eye contact from their child immediately
Administer eye prophylactic antibiotics to newborns within 24 hours after birth.
The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient?
Administer an opioid medication to help the patient sleep.
Keep the door open during the night.
Open the shades at night
Provide the patient with earplugs.
The nurse is caring for a patient diagnosed with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care?
Patient will carry a pen and a pad of paper around for communication.
Patient will recover full use of speech vocabulary in 1 day.
Patient will thicken drinks to prevent aspiration.
Patient will communicate nonverbally
The nurse caring for a group of patients is monitoring for sensory deprivation. Which patient will the nurse monitor most closely?
A patient in the ICU under constant monitoring following a myocardial infarction
A patient on the unit with tuberculosis on airborne precautions
A patient who recently had a stroke and has left-sided weakness
A patient receiving hospice care for end-stage lung cancer
A nurse is caring for an older-adult patient on bed rest with potential sensory deprivation. Which action will the nurse take?
Offer the patient a back rub.
Hang a “Do not disturb” sign on patient’s door.
Ask the patient “Would you like a newspaper to read?
Place the patient in the room farthest from the nurses’ station.
The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a “Do not disturb” sign on the door. A few hours later, the nurse notices a surgeon who is not involved in the patient’s care attempting to enter the room. Which response by the nurse is most appropriate?
Call for security to remove the surgeon.
Allow the surgeon to enter
Firmly explain that the patient does not wish to have visitors at this time
Scold the surgeon for not obeying the sign and respecting the patient’s wishes.
The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion?
Keep a day-by-day calendar at the patient’s bedside.
Place a patient observer in the patient’s room for safety.
Assess the patient’s level of consciousness and document every 4 hours.
Prepare to discharge once the patient is awake, alert, and oriented.
A nurse establishing a relationship with the patient who is severely visually impaired is teaching the patient how to contact the nurse for assistance. Which action will the nurse take?
Place a raised Braille sticker on the call button
Explain to the patient that a staff person will stop by once an hour to see if the patient needs anything.
Instruct the patient to tell a family member to get the attention of the staff.
Color code the nurse call system.
The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority?
Hearing
Vision
Smell
Taste
A nurse is teaching a patient about vision. In which order will the nurse describe the pathway for vision, beginning with the first structure? 1. Lens 2. Pupil 3. Retina 4. Cornea 5. Optic nerve
2, 1, 4, 5, 3
1, 2, 4, 3, 5
4, 2, 1, 3, 5
5, 2, 4, 1, 3
A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action by an assistive personnel (NAP) demonstrates understanding of the needs of this patient?
Dressing the left side first
Dressing the right side first
Dressing the lower extremities first
Dressing the upper extremities first
A home care nurse is inspecting a patient’s house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply.)
Stairway faintly lit
Bathtub with grab bars
Scatter rugs in the kitchen
Absence of smoke alarms
Low-pile carpeting in the living room
Level thresholds between bathroom and bedroom
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