49 sensory perception

Question 1

1. A patient has been on contact isolation for 4 days because of a hospital-acquired infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Which are the correct nursing interventions to reduce sensory deprivation? (Select all that apply.)

Answer 1

1. Teaching how activities such as reading and using crossword puzzles provide stimulation
2. Turning on the lights and opening the room blinds
3. Sitting down, speaking, touching, and listening to his feelings and perceptions

Question 2

2. The home care nurse is instructing an assistive personnel about interventions to facilitate location of items for patients with vision impairment. Which are effective strategies for enhancing a patient’s impaired vision? (Select all that apply.)

Answer 2

2. Use of warm incandescent lighting
3. Use of yellow or amber lenses to decrease glare
4. Use of adjustable blinds, sheer curtains, or draperies

Question 3

3. An older adult patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitates communication with her? (Select all that apply.)

Answer 3

3. Face the patient when speaking; demonstrate ideas you wish to convey.
4. Verify that the information that has been given has been clearly understood.

Question 4

4. A patient is returning to an assisted-living apartment following a diagnosis of declining, progressive visual loss. Although she is familiar with her apartment and residence, she reports feeling a little uncertain about walking alone. There is one step into her apartment. Her children are scheduling themselves to be available to their mom for the next 2 weeks. Which of the following approaches will you teach the children to assist ambulation? (Select all that apply.)

Answer 4

2. Have her grasp your arm just above the elbow and walk at a comfortable pace.
3. Stand next to your mom at the top and bottom of stairs.

Question 5

5. A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair?

Answer 5

3. Guide patient’s hand to nurse’s arm, resting just above the elbow.
4. Position yourself one-half step in front of patient.
5. Tell patient when you are approaching the chair.
6. Walk at a relaxed pace.
7. Position patient’s hand on back of chair.

Question 6

6. A patient with progressive vision impairments had to surrender his driver’s license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? (Select all that apply.)

Answer 6

1. Sharing information about senior transportation services
2. Providing information about local social groups in the patient’s neighborhood
3. Recommending that the patient consider making living arrangements that will put him closer to family or friends

Question 7

7. A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse’s priority interventions include which of the following? (Select all that apply.)

Answer 7

3. Placing necessary objects such as the nurse call system and water in front of the patient to prevent falls caused by reaching
4. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye
5. Alerting other nurses and health care providers about patient’s visual status during hand-off reports

Question 8

8. An older adult is admitted from a skilled nursing home to a medical unit with pneumonia. A review of the medical record reveals that he had a stroke affecting the right hemisphere of the brain 6 months ago and was placed in the skilled nursing home because he was unable to care for himself. Which of these assessment findings does the nurse expect to find? (Select all that apply.)

Answer 8

2. Inattention and neglect, especially to the left side

4. Visual spatial alterations such as loss of half of a visual field

Question 9

9. A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, “I think my hearing aid is broken. I can’t hear anything.” After determining that the patient’s hearing aid works and that the patient is having trouble managing the hearing aid at home, which of the following teaching strategies does the nurse implement? (Select all that apply.)

Answer 9

1. Demonstrate hearing aid battery replacement.
2. Review method to check volume on hearing aid.
3. Discuss the importance of having wax buildup in the ear canal removed.