Chapter 31: Cognitive and Sensory Alterations

Question 1

1.	A nurse is caring for a patient with a stroke that has impacted her ability to see. Which area of the brain was likely impacted by the stroke that is responsible for visual function?
a.
Parietal lobes
b.
Frontal lobes
c.
Occipital lobes
d.
Temporal lobes

Answer 1

ANS: C

Question 2

2.	The family of a patient who was in a motor vehicle accident tells you he “just isn’t the same person before the crash.” You know this is likely because of the injury to what area of his brain?
a.
Parietal lobes
b.
Frontal lobes
c.
Occipital lobes
d.
Temporal lobes

Answer 2

ANS: B

Question 3

3.	The nurse is educating the family of a patient in the intensive care unit about the patient’s cognitive status, including her current problem of delirium. Which statement by the family indicates a need for further education?
a.
“The delirium can be caused by sensory overload.”
b.
“The delirium is reversible.”
c.
“The delirium is a mood disorder.”
d.
“The delirium is a state of confusion.”

Answer 3

ANS: C

Question 4

4. The nurse is caring for a patient with depression. Which statement by the patient indicates a need for further education?
   a.
   “Depression can be caused by chemical changes in the brain.”
   b.
   “Depression is always treated with medication.”
   c.
   “Depression is a mood disorder.”
   d.
   “Depression can have a rapid onset.”

Answer 4

ANS: B

Question 5

5.	The nurse is caring for a patient who is complaining of tingling in her hands and fingers. The nurse knows this is a sign of what electrolyte imbalance?
a.
Hyponatremia
b.
Hypernatremia
c.
Hypocalcemia
d.
Hypercalcemia

Answer 5

ANS: C

Question 6

6. The nurse is providing discharge instructions to an older adult who is being discharged with orthostatic hypotension. Which of the following responses by the patient indicates a need for further education?
   a.
   “I should take my blood pressure once a day at home.”
   b.
   “I should get up quickly to avoid my blood pressure dropping.”
   c.
   “I should drink plenty of water during the day.”
   d.
   “I should get up slowly and carefully.”

Answer 6

ANS: B

Question 7

7. The nurse is assessing the patient’s ability to hear. Which is the correct procedure for the doing this?
   a.
   The nurse whispers to the patient while standing on each side of the patient.
   b.
   The nurse speaks in a normal voice while standing on each side of the patient.
   c.
   The nurse speaks in a normal voice while standing directly in front of the patient.
   d.
   The nurse speaks in a normal voice while standing slightly behind the patient.

Answer 7

ANS: D

Question 8

8.	The nurse notices her 50-year-old patient is holding his lunch menu at arm’s length while trying to read his choices. This is an indication of:
a.
retinopathy.
b.
presbyopia.
c.
cataracts.
d.
macular degeneration.

Answer 8

ANS: B

Question 9

9.	The nurse is providing discharge education to her patient with diabetes regarding foot care. Which of the following statements by the patient indicates a need for further education?
a.
“I can go barefoot outside only in the summer.”
b.
“I should wear good fitting shoes.”
c.
“I cannot soak my feet in a hot tub.”
d.
“I can use lotion on my feet.”

Answer 9

ANS: A

Question 10

10. An appropriate goal for a patient with the diagnosis of acute confusion is:
    a.
    the patient will use the call light before getting out of bed within 48 hours.
    b.
    the patient will use a calendar to remember the date within 48 hours.
    c.
    the patient will respond appropriately to questions about place within 48 hours.
    d.
    the patient will remain within the unit while in long-term care.

Answer 10

ANS: C

Question 11

11. An appropriate goal for a patient with a diagnosis of social isolation is:
    a.
    the patient will participate in cognitive exercises.
    b.
    the patient will interact with other residents during activities.
    c.
    the patient will communicate basic needs through use of photos.
    d.
    the patient will remain within the unit while in long-term care.

Answer 11

ANS: B

Question 12

12. The nurse is educating the family to care for a patient at home with cognitive alterations. Which statement by the family indicates a need for further education?
    a.
    “I should keep the home free of scissors.”
    b.
    “I should minimize the number of visitors.”
    c.
    “I should use push-button door locks.”
    d.
    “24-hour supervision may become necessary.”

Answer 12

ANS: C

Question 13

13.	The nurse is delegating care to an unlicensed assistive personnel (UAP) to a patient who has sensory overload. Which statement by the UAP indicates a need for further orientation?
a.
“I should keep the noise levels low.”
b.
“I should schedule all the care together.”
c.
“I should keep the room well lit.”
d.
“I should allow the family to visit.”

Answer 13

ANS: C

Question 14

14. The nurse is providing discharge instructions to a patient with visual alterations. Which statement by the patient indicates a need for further education?
    a.
    “I should make sure the passageways are wide.”
    b.
    “I should remove all the throw rugs.”
    c.
    “I should keep the lights dim.”
    d.
    “I can use a cane to feel for objects in front of me.”

Answer 14

ANS: C

Question 15

1. The nurse is completing her assessment of an older adult and notices some cognitive impairment not normally associated with aging. Which of these alterations would prompt further follow-up? (Select all that apply.)
   a.
   The patient does not remember where her son lives.
   b.
   The patient is unable to balance her checkbook.
   c.
   The patient got lost in a city she never traveled to before.
   d.
   The patient often has difficulty remembering words.
   e.
   The patient got lost going to her usual grocery store.

Answer 15

ANS: A, B, D, E

Question 16

2. You are providing education to the family of a patient being discharged with dementia. Which statement by the family indicates a good level of understanding of dementia? (Select all that apply.)
   a.
   “The condition is permanent and has an acute onset.”
   b.
   “Alzheimer’s is the most common type of dementia.”
   c.
   “The condition worsens over time.”
   d.
   “I should observe for wandering behavior.”
   e.
   “Agitation can be worse in the evening.”

Answer 16

ANS: B, C, D, E

Question 17

3. The nurse is caring for a patient who suffered a stroke on the right side of the brain. The nurse is careful to implement what safety measures? (Select all that apply.)
   a.
   “Make sure to put a picture board in the room to communicate with the patient.”
   b.
   “Place the call light on the patient’s left side.”
   c.
   “Leave on a light in the bathroom at night for good visibility.”
   d.
   “Place the call light on the patient’s right side.”
   e.
   “Make sure there are no trip hazards in the patient’s room.”

Answer 17

ANS: C, D, E

Question 18

4. The nurse is performing a health history to determine the patient’s cognitive status. Which questions will be best suited to elicit the information needed? (Select all that apply.)
   a.
   “Are you able to drive to the store or do errands?”
   b.
   “Do you live with anyone?”
   c.
   “Do you ever feel sad?”
   d.
   “Are you able to smell different foods?”
   e.
   “Have you noticed any difficulty adding up numbers?”

Answer 18

ANS: A, E

Question 19

5.	The nurse is performing a health history to determine the patient’s sensory status. Which questions will be best suited to elicit the information needed? (Select all that apply.)
a.
“Do you ever lose your balance?”
b.
“Do you wear glasses?”
c.
“Do you read the newspaper?”
d.
“Can you feel the difference between hot and cold water?”
e.
“Do you wear a hearing aid?”

Answer 19

ANS: A, B, D, E

Question 20

6.	The nurse is caring for a diabetic patient who has had a long history of poor glucose control. For what complications is the patient at risk? (Select all that apply.)
a.
Sudden loss of consciousness
b.
Diabetic retinopathy
c.
Stroke
d.
Peripheral neuropathy
e.
Memory loss

Answer 20

ANS: B, C, D, E

Question 21

7. The nurse is caring for a patient who is hospitalized with cognitive impairment. The following interventions will assist the patient in orientation: (Select all that apply.)
   a.
   Keep a photo of the family in the room.
   b.
   Use a clock on the wall.
   c.
   Make sure the room is kept bright and well lit.
   d.
   Avoid moving the patient from room to room.
   e.
   Have the nurse introduce himself or herself to the patient.

Answer 21

ANS: A, B, D, E

Question 22

8.	The nurse is caring for a patient with expressive aphasia. Which interventions will assist the nurse in communicating with the patient? (Select all that apply.)
a.
Use simple phrases.
b.
Speak loudly.
c.
Use yes/no questions.
d.
Use a picture board.
e.
Be patient and unrushed.

Answer 22

ANS: A, C, D, E

Question 23

9.	The nurse is caring for a patient with receptive aphasia. Which interventions will assist the nurse in communicating with the patient? (Select all that apply.)
a.
Use simple phrases.
b.
Speak softly.
c.
Stand in front of the patient.
d.
Use a picture board.
e.
Be patient and unrushed.

Answer 23

ANS: A, C, D, E

Question 24

10. The nurse is preparing discharge instructions for a patient who has tactile alterations in his legs. Which instructions should be included? (Select all that apply.)
    a.
    Verify bath water temperature is approximately 39.5° C.
    b.
    Do not use hot or cold therapy on any extremity.
    c.
    Use sturdy shoes when walking outside or on hard surfaces.
    d.
    Report any changes in skin color on your legs to your health care provider.
    e.
    Set your water heater so that scalding is not possible.

Answer 24

ANS: C, D, E

Question 25

11. The nurse is preparing discharge instructions for a patient who has equilibrium alterations. Which instructions should be included? (Select all that apply.)
    a.
    Use grab bars in the tub and/or shower at home.
    b.
    Keep rooms well lit and focus ahead when walking.
    c.
    Change positions quickly to avoid dizziness.
    d.
    Use a cane or walker for stability.
    e.
    Ride in the back seat of the car and look ahead.

Answer 25

ANS: A, B, D