C. CH 29 Sensory Flashcards
A patient is refusing to take his prescribed medication. The patient states that the government is out to get him and is poisoning all of his medication. The nurse understands that the patient is experiencing A) an illusion. B) a delusion. C) an hallucination. D) confusion.
B) a delusion.
The nurse is preparing a care plan for a patient with a nursing diagnosis of Disturbed Sensory Perception. Which of the following would be appropriate goals for this diagnosis? Select all that apply.
A) The patient will demonstrate an understanding of contributing factors to disturbed sensory perceptions by reducing or eliminating them during the hospital stay.
B) The patient will not fall during the hospital stay.
C) The patient will develop an effective communication mechanism during the hospital stay.
D) The nurse will use a communication board when speaking with the patient.
E) The nurse will assist the patient with ADLs as needed during the hospital stay.
A) The patient will demonstrate an understanding of contributing factors to disturbed sensory perceptions by reducing or eliminating them during the hospital stay.
B) The patient will not fall during the hospital stay.
C) The patient will develop an effective communication
3. The nurse understands that when a patient is talking about the voices in their head, the patient is experiencing A) a delusion. B) an hallucination. C) an illusion. D) confusion.
B) an hallucination.
The nurse is caring for a patient at risk for sensory overload. What interventions should the nurse implement? Select all that apply.
A) Remove clutter from the patients room
B) Implement measures to reduce the patients pain
C) Assist with all ADLs
D) Limit interruptions to the patients rest/sleep times
E) Limit extraneous noise
A) Remove clutter from the patients room
B) Implement measures to reduce the patients pain
D) Limit interruptions to the patients rest/sleep times
E) Limit extraneous noise
The nurse is caring for a patient at risk for sensory deprivation. What interventions should the nurse implement to decrease the patients risk? Select all that apply.
A) Encouraging the patients family to bring in personal objects.
B) Keeping the television on at all times
C) Placing a clock and calendar in the patients room
D) Brushing the patients hair
E) Speaking slowly and clearly to the patient
A) Encouraging the patients family to bring in personal objects.
C) Placing a clock and calendar in the patients room
D) Brushing the patients hair
E) Speaking slowly and clearly to the patient
Which of the following patients is at greatest risk of sensory overload?
A) A 17-year-old on bedrest after a surgical procedure
B) A 55-year-old, newly diagnosed with diabetes, in a private room in a hospital
C) An 88-year-old on a ventilator in an intensive care unit
D) An 8-year-old in isolation in a private room in a hospital
C) An 88-year-old on a ventilator in an intensive care unit
Which patient is at greatest risk of developing sensory deprivation?
A) An 84-year-old with progressive hearing loss living in an assisted living facility
B) A 50-year-old newly diagnosed with breast cancer and having first chemotherapy treatment today
C) A 32-year-old with a fractured pelvis, on bedrest in a private room
D) An 18-year-old with a traumatic head injury who is in an intensive care unit
C) A 32-year-old with a fractured pelvis, on bedrest in a private room
A nurse has just finished a presentation to a group of nursing assistants on ways to assist patients with sensory perception issues, such as low vision or hearing. What statement by a nursing assistant suggests a need for further education?
A) I will stand directly in front of the patient and speak slowly.
B) I will move the furniture around depending on what activities are planned for the day.
C) I will use bright contrasting colors when making signs.
D) I will keep fresh flowers in the television room.
B) I will move the furniture around depending on what activities are planned for the day.
The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.
A) Depression
B) Increased appetite
C) Sleeplessness
D) Decreased interest in activities
E) Increased interest in interactions with others
A) Depression
C) Sleeplessness
D) Decreased interest in activities
A hospitalized patient who refuses to eat because she fears that the kitchen personnel are poisoning her food is experiencing
Hallucinations
Anorexia
Agoraphobia
Delusions
Delusions
When admitting a wheelchair-bound paraplegic patient to the hospital, the nurse assesses the patient for injuries that may occur as a result of sensory Alteration Overload Deprivation Progression
Alteration
A patient in the intensive care unit will experience less sensory overload If a clock displays date, time, AM/PM If the nurse silences the alarms If the nurse provides touch every hour If the family visits at all times
If a clock displays date, time, AM/PM
The nurse determines that when a female patient who underwent a mammogram earlier in the day is asked to have a breast ultrasound and is informed that she demonstrates signs of breast malignancy, the patient is at risk for experiencing sensory A) Adaptation B) Deprivation C) Stimulation D) Overload
D) Overload
When the patient who has been hospitalized for 8 days for skin grafting tells the nurse that he is bored, depressed, and restless, the nurse determines that the patient is experiencing sensory Deprivation Adaptation Perception Overload
Deprivation
To meet the learning needs of the older adult, the nurse incorporates which of the following considerations in planning to teach a 73-year-old diabetic patient about insulin administration?
Requesting hearing aids to help the patient receive information
Using numerous handouts and detailed teaching plan
Allowing more time for the processing of the information
Demonstrating a wide variety of syringes and techniques
Allowing more time for the processing of the information
