Ch 44 Sensory Stimulation/ Neuro

Question 1

What is “Presbycusis”?

Answer 1

Hearing decrease due to age (high tone + deterioration)

Question 2

What is “Presbyopia”?

Answer 2

Visual impairment due to age.

Question 3

What is R.A.S?

Answer 3

The reticular activating system (RAS) which monitors, regulates incoming sensory stimuli.

Question 4

What is “Stereognosis”?

Answer 4

Sense that perceives the solidity of objects and their size, shape and texture.

• First sense to go with Alzheimer’s disease

Question 5

What is “Kinesthesia”?

Answer 5

Refers to the awareness of positioning of body parts and body movement.

Question 6

What is “Proprioception”?

Answer 6

Subconscious visual of position of body + limbs even blind-folded.

Question 7

What is the “Locked-in Syndrome”?

Answer 7

It is a full consciousness, sleep wake cycle, quadriplegic, INTACT auditory, visual and emotional.

Question 8

What defines a vegetative stage?

Answer 8

Patient cannot be aroused, posture withdrawals, random smile, grimace and only respond to noxious stimuli.

Question 9

What are the different states of unconsciousness?

Answer 9

• Asleep
• Lethargic = very sleepy
• Stupor = can be aroused by extreme stimuli
• Coma = cannot be aroused

Question 10

What are the different states of consciousness?

Answer 10

• Delirium =abrupt onset
• Dementia = not reversible
• Confusion = sign of electrolyte imbalance and is temporary
• Somnolence = oriented but sleepy
• Chronic vegetative state

Question 11

What is “Sensory Deprivation”?

Answer 11

• decrease input
• monotonous input, meaningless and unpatterned

–> RAS is no longer able to project a normal level of activation to the brain.

Question 12

What is “Sensory overload”?

Answer 12

Condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli.
–> feeling “out of control”

Question 13

What is “Sensory deficit”?

Answer 13

Impaired or absent functioning in one or more senses.

Ex: impaired sight + hearing, altered taste, numbness and paralysis.

Question 14

What are signs of “Sensory deprivation”?

Answer 14

• Physical behaviors
• Escape behaviors
• Changes in perception = unusual body sensations
• Changes in cognitive behaviors = inability to concentrate
• Changes in affective behaviors = crying, increase irritability, panic.

Question 15

What can the nurse do to assist a patient suffering from “Sensory overload”?

Answer 15

• Orient the patient to person, place, and time
• Decrease environment noise
• Encourage patient to participate in nursing care

Question 16

What interventions can the nurse implement during “Sensory overload”?

Answer 16

• Identify distressing stimuli
• Reduce and eliminate stimuli (w/out causing sensory deprivation!)
• Provide periods of rest
• Elderly and CVA patients often experience confusion or agitation

Question 17

How does the nurse appropriately communicates with a confused patient?

Answer 17

• Orient frequently
• Speak calmly, simply and directly
• Frequent face to face contact
• Allow adequate time to process
• Emphasize patient strength
• Reinforce reality

Question 18

How does the nurse communicate with an unconscious patient?

Answer 18

• Be careful what is said in their presence
• Assume the person can hear you
• Speak to the person before touching
• Keep surrounding noises down to a minimum

Question 19

What are the different types of language dysfunctions?

Answer 19

1) Aphasia = loss to comprehend
2) Dysphasia = impairment to comprehend language
3) Expressive Aphasia = difficulty to express speech
4) Receptive Aphasia = language content, trouble processing + making sense
5) Global Aphasia = impairment to comprehend + express –> usually non-verbal

Question 20

What are the S x S of Hypoglycemia?

Answer 20

• Hunger
• Shakiness
• Nervousness
• Sweating
• Dizziness
• Confusion
• Anxiety
• Weakness

Question 21

What are the S x S of Hyperglycemia?

Answer 21

• ⬆ thirst
• Headaches
• Difficulty concentrating
• Blurred vision
• Fatigue
• Frequent urination

Question 22

What are the 3 components of the Glasgow Coma Scale?

Answer 22

1) Eye Opening
2) Motor Response
3) Verbal Response

Question 23

How is “Eye Opening” scored on the Glasgow Coma Scale?

Answer 23

4 = Spontaneous
3 = To verbal command
2 = To pain
1 = No response

Question 24

How is “Motor Response” scored on the Glasgow Coma Scale?

Answer 24

6 = To verbal command
5 = To localized pain
4 = Flexes/withdraws
3 = Flexes abnormally
2 = Extends abnormally
1 = No response

Question 25

How is “Verbal Response” scored on the Glasgow Coma Scale?

Answer 25

5 = Oriented/Talks
4 = Disoriented/Talks
3 = Inappropriate words
2 = Incomprehensible sounds
1 = No response

Question 26

What score on the Glasgow Coma Scale defines a state of coma?

Answer 26

A score of 7 or less.

Question 27

Name 8 factors that can affect a person’s state of awareness?

Answer 27

1) Inadequate blood flow
2) Fluid and electrolyte imbalance
3) Altered nutrition and metabolism
4) Infectious process
5) Inadequate sleep and rest

Question 28

When assessing swallowing capabilities, which cranial nerve is being tested?

Answer 28

Cranial nerve X = Vagus nerve

Question 29

Cerebellar function includes what human responses and how can you assess this function?

Answer 29

1) Cerebellar response includes balance, coordination and fine motor skills.
2) Cerebellar function can be assessed by having the pt touch each finger to their thumb, also you can assess for ataxia.

Question 30

What is Ataxia and what 2 tests can be used to assess for it?

Answer 30

1) Ataxia - Loss of voluntary control of muscles which is controlled by the cerebellum.
2) RN can use the pronator drift or Ronburg test to assess for it.