Chapter 30 Sensory Flashcards
A patient must place his hand on the wall to keep his balance when walking. He leans when sitting and has difficulty knowing when his body is vertical and sensing the position of his body in space. Which type of receptor is probably involved?
1) Photoreceptors
2) Chemoreceptors
3) Proprioceptors
4) Thermoreceptors
Answer:
3) Proprioceptors
Rationale:
Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. Photoreceptors located in the retina of the eyes detect visible light. Chemoreceptors are located in the taste buds and epithelium of the nasal cavity. They play a role in taste and smell. Thermoreceptors in the skin detect variations in temperature.
Which medication might blunt a patient’s perception of various kinds of stimuli?
1) Furosemide (Lasix)
2) Metoprolol (Lopressor)
3) Morphine sulfate
4) Metoclopramide (Reglan)
Answer:
3) Morphine sulfate
Rationale:
Central nervous system depressants, such as the opioid analgesic morphine, blunt the perception of stimuli. Furosemide, metoprolol, and metoclopramide do not affect the patient’s perception of stimuli.
A patient complains, “Everything tastes so bland. I add salt, pepper, and sugar to everything just to make it so I can taste it.” Which nutrient deficiency might be responsible for his problem? Select all that apply.
1) Vitamin A
2) Vitamin B12
3) Iron
4) Zinc
Answer:
2) Vitamin B12
4) Zinc
Rationale:
Deficiencies in vitamin B12 or zinc may cause diminished taste. Deficiencies in vitamin A and iron do not cause diminished taste.
After sustaining an eye injury in a baseball game, a patient complains of blurred and distorted vision. Which visual deficit is this patient most likely experiencing?
1) Macular degeneration
2) Astigmatism
3) Strabismus
4) Glaucoma
Answer:
2) Astigmatism
Rationale:
Astigmatism is caused by irregular curvature of the cornea or lens that results from injury, infection, or an inherited trait. Astigmatism causes blurred and distorted vision.
A patient who has been unable to sleep for several nights has experienced a change in mental status. He does not know what day it is, or where he is. His speech and movements are slowed, and he seems dazed and stupefied. He cannot follow simple directions such as, “Hold out your hand.” Which nursing diagnosis is most appropriate for this patient?
1) Chronic Confusion
2) Acute Confusion
3) Impaired Environmental Interpretation Syndrome
4) Impaired Memory
Answer:
2) Acute Confusion
Rationale:
Acute Confusion is the abrupt onset of transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, and the sleep-wake cycle. This diagnosis is used for those who exhibit signs of sleep deprivation. Chronic Confusion may be used for patients with Alzheimer’s disease. Impaired Environmental Interpretation Syndrome is used when there is a lack of consistent orientation to person, place, time, or circumstances over more than 3 to 6 months. Impaired Memory is the inability to remember or recall bits of information.
A patient in a nursing home is deaf and nearly blind. He is confined to bed most of the time. Which of the following interventions would help to promote optimal sensory function?
1) Keep the television on during waking hours.
2) Put colorful artwork on the walls.
3) Provide aromatherapy for him.
4) Keep the room dark and quiet.
Answer:
3) Provide aromatherapy for him.
Rationale:
Aromatherapy would stimulate the patient’s sense of smell, which apparently is still intact. When one sense is impaired, it is important to stimulate others. This patient is at risk for sensory deprivation because he has no auditory stimuli, limited visual and tactile stimuli, and because of being confined to bed, limited social interaction. Nursing interventions should focus on providing appropriate stimuli. Although television can provide stimulation when used appropriately, it is meaningless when overused. In addition, this patient could not hear or see it. He would not be able to see artwork on the walls well enough for it to provide stimulation. Keeping the room dark and quiet would further reduce the limited stimuli from light that the patient is able to perceive. Furthermore, “quiet” would be irrelevant for a patient who is deaf.
The nurse in the intensive care unit is developing a seizure precaution plan for a patient with a history of epilepsy. What is the most important goal for this patient?
1) Protection from injury during seizures
2) Prevention of seizure activity
3) Padding for siderails, headboard, and footboard
4) Assessment for an aura prior to the seizure
Answer:
1) Protection from injury during seizures
Rationale:
The goal of seizure precautions is to protect the patient from injury during the seizure event. Seizure precautions are instituted for patients with a new diagnosis of a seizure disorder, any seizure activity within the past 12 months, frequent seizure activity, history of head trauma, and withdrawal from antiseizure medication. Although the nurse can attempt to prevent seizure activity possibly through the use of medications, the nurse can fully prevent seizures using nonpharmacological measures. Assessing a patient for an aura prior to a seizure is assessment (not a goal). Padding side rails, headboard, and footboard are nursing interventions—not nursing goals for care.
A patient with Parkinson’s disease is at risk for which complication?
1) Impaired kinesthesia
2) Macular degeneration
3) Seizures
4) Xerostomia
Answer:
1) Impaired kinesthesia
Rationale:
Patients with Parkinson’s disease are at risk for impaired kinesthesia, placing them at risk for falling. Drooling, not excessive dry mouth (xerostomia) is common with Parkinson’s disease. Seizures and macular degeneration are not associated with Parkinson’s disease.
A patient is admitted with an exacerbation of asthma. Which factor places the patient at highest risk for sensory overload?
1) Administering albuterol for bronchodilation as needed
2) Administering a tranquilizer intravenously every 2 hours
3) Delivering oxygen at 6 L/min via nasal cannula
4) Maintaining complete bedrest in a quiet, dimly lit room
Answer:
1) Administering albuterol (a central nervous stimulate) every as needed
Rationale:
Medications that stimulate the central nervous system, such as albuterol, place the patient at risk for sensory overload. A tranquilizer and a quiet, darkened room may help the patient to relax, thus preventing sensory overload. If the patient’s oxygen needs are met with oxygen at 6 L/min via nasal cannula, the patient should not experience sensory overload related to oxygen therapy alone. Oxygen deprivation can lead to air hunger and feelings of anxiety.
You are using the Glasgow Coma Scale to assess a client's level of consciousness (LOC). Which of the following responses to stimuli does this scale assess? SELECT ALL THAT APPLY. 1) Brainstem reflexes 2) Eye responses 3) Respirations 4) Motor responses 5) Verbal responses 6) Heart rate responses
ANS - 2,4,5
Feedback 1: The Full Outline of Un-Responsiveness (FOUR) scale, not the Glasgow scale, assesses brainstem reflexes and respirations.
Feedback 2: The Glasgow Coma Scale is commonly used to assess LOC. It assesses eye, motor, and verbal responses.
Feedback 3: The Full Outline of Un-Responsiveness (FOUR) scale, not the Glasgow scale, assesses brainstem reflexes and respirations.
Feedback 4: The Glasgow Coma Scale is commonly used to assess LOC. It assesses eye, motor, and verbal responses.
Feedback 5: The Glasgow Coma Scale is commonly used to assess LOC. It assesses eye, motor, and verbal responses.
Feedback 6: The Glasgow Coma Scale does not assess for heart rate responses.
While you are performing a focused nursing assessment of a patient’s hearing, he mentions that lately he has begun to hear a ringing sound in his ears at night when he lies down to sleep. Which of the following hearing deficits is this client most likely experiencing?
1) Presbycusis
2) Tinnitus
3) Nerve deafness
4) Otitis media
ANS - 2
Tinnitus is a term used to describe ringing in the ears. Most tinnitus comes from damage to the microscopic endings of the nerve in the inner ear, for example, trauma, turbulent blood flow, hypertension, ear infection, medications, otosclerosis, or arthritic changes of the bones of the ear.
As you are walking along the sidewalk, you feel your cell phone vibrating in your pocket. Which of the following receptors allow you to receive this stimulus?
1) Mechanoreceptors
2) Thermoreceptors
3) Proprioceptors
4) Chemoreceptors
ANS - 1
Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.
Thermoreceptors in the skin detect variations in temperature.
Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable us to sense the position of our body in space (proprioception).
Chemoreceptors for taste are located in our taste buds.
You are caring for a client with severely limited vision. Which of the following interventions should you make?
SELECT ALL THAT APPLY.
1) Provide an uncluttered environment.
2) Provide closed-caption television.
3) Consider conversion to text-telephone service.
4) Consider books on tape or in Braille for the client.
5) Avoid distracting the client’s guide dog.
6) Keep the bed in a high position.
ANS - 1,4,5
Feedback 1: For clients with severely limited vision, provide an uncluttered environment and do not rearrange furniture.
Feedback 2: For clients with a hearing deficit, not severely limited vision, provide closed-caption television.
Feedback 3: For clients with a hearing deficit, not severely limited vision, consider conversion to text-telephone service.
Feedback 4: For clients with severely limited vision, consider books on tape or in Braille.
Feedback 5: For clients with severely limited vision, avoid distracting the client’s guide dog.
Feedback 6: For clients with severely limited vision, keep the bed in a low, not high, position.
You are caring for a 12-year-old boy with autism who was recently admitted to the hospital. His mother looks worried, and when you ask her what's wrong, she says, "His senses get overwhelmed easily, and there's so much going on here." Which of the following are signs of sensory overload, which you should observe for in this client? SELECT ALL THAT APPLY. 1) Depression 2) Preoccupation with heart palpitations 3) Anxiety 4) Inability to concentrate 5) Restlessness 6) Delusions
ANS - 3,4,5
Feedback 1: Depression is a sign of sensory deprivation, not overload.
Feedback 2: Preoccupation with somatic complaints, such as heart palpitations, is a sign of sensory deprivation, not overload.
Feedback 3: Anxiety is a sign of sensory overload.
Feedback 4: Inability to concentrate is a sign of sensory overload.
Feedback 5: Restlessness is a sign of sensory overload.
Feedback 6: Delusions are a sign of sensory deprivation, not overload.
You are performing a focused physical examination of a client with diabetes. Which of the following sensory deficits, associated with this client’s condition, should concern you most?
1) Blindness
2) Hearing impairment
3) Dyskinesia
4) Anosmia
ANS - 1
Some diseases affect specific sensory organs. For example, diabetic retinopathy is the leading cause of blindness among adults aged 20 to 74 years.
Hearing impairment is not associated with diabetes.
Dyskinesia, or difficulty moving, is not associated with diabetes.
Anosmia, or lack of the sense of smell, is not associated with diabetes.
