Chapter 44 Flashcards
The nurse is assessing a client’s gustatory function. What approach by the nurse will assist in assessing this sensation
A) “Tell me if the taste on your tongue is sweet, sour, bitter, or salty.”
B) “Repeat the words that I speak softly to you.”
C) “Please read this paragraph to me.”
D) “Close your eyes and tell me what you smell.”
A) “Tell me if the taste on your tongue is sweet, sour, bitter, or salty.”
Gustatory sensations equate to taste. Repeating words assesses auditory function. Reading a paragraph assesses visua
disturbances. Smelling assesses for olfactory disturbances.
What term is used to describe the sense, usually at a subconscious level, of the movements and position of the body
(especially its limbs) independent of vision?
A) Stereognosis
B) Visceral
C) Proprioception
D) Sensory perception
C) Proprioception
Proprioception describes the sense, usually at a subconscious level, of the movements and position of the body (especially its limbs) independent of vision. Stereognosis is the perception of the solidity, size, shape, and texture of
body parts. Visceral refers to inner organs and reception. Sensory perception is the conscious process of selecting, organizing, and interpreting data from the senses into meaningful information
A client says, “What is that awful smell?” What sense is being used? A) Olfactory B) Gustatory C) Tactile D) Auditory
A) Olfactory
The senses by which a person maintains contact with the external environment are vision (visual), hearing (auditory), smell (olfactory), taste (gustatory), and touch (tactile).
Which of the following best describes a stimulus?
A) A sense organ that receives a message and converts it into a nerve impulse
B) Conduction along a nerve pathway from the receptor to the brain
C) Reception and translation of an impulse into a sensation
D) An act or agent that initiates a response by the nervous system
D) An act or agent that initiates a response by the nervous system
For a person to receive the necessary data to experience the world, there must first be a stimulus. A stimulus is an agent,
act, or other influence capable of initiating a response by the nervous system
After assessing a client, a nurse documents the state of awareness as confused. What part of the brain controls awareness? A) Cranial nerves B) Reticular activating system C) Hypothalamus D) Medulla
B) Reticular activating system
To receive stimuli and respond appropriately, the brain must be alert or aroused. The reticular activating system (RAS)
mediates arousal.
How would a nurse document the condition in which a client has a normal state of awareness?
A) “Aware of self and environment, responsive, well-oriented.”
B) “Easily distracted, alternates between drowsiness and excitability.”
C) “Disoriented, restless, agitated, hallucinating.”
D) “Can’t be aroused and does not respond to stimuli.”
A) “Aware of self and environment, responsive, well-oriented.”
A normal state of awareness is one in which there is awareness of self and the external environment, including being well-oriented and responsive.
A nurse documents the following on a client chart: “client manifests difficulties with spatial orientation, memory language, and changes in personality.” What state of arousal/awareness does this describe? A) Delirium B) Dementia C) Confusion D) Locked-in syndrome
A) Delirium
Difficulties with spatial orientation, memory, language, and changes in personality occur with delirium. Disorientation,
restlessness, confusion, hallucinations, and agitation, alternating with other conscious states, occurs with dementia. In
confusion, the client manifests reduced awareness, is easily distracted, easily startled by sensory stimuli, and alternates between drowsiness and excitability. In locked-in syndrome, the client displays full consciousness, sleep–wake cycles are present, and auditory and visual function and emotions are preserved.
Which of the following hospital units is more likely to cause severe sensory alterations? A) General unit B) Short-stay surgery C) Eye clinic D) Intensive care
D) Intensive care
Severe sensory alterations can occur when a client is admitted to a health care agency, especially in certain areas such as
intensive care units (termed intensive care unit [ICU] psychosis)
In which of the following health care settings is a client more likely to be at risk for sensory deprivation? A) Hospital newborn nursery B) Community health center C) Emergency department D) Long-term care
D) Long-term care
Sensory deprivation occurs when a client experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. In this question, clients in long-term care would be most at risk for sensory deprivation.
What type of cognitive responses might a nurse assess in a client with sensory deprivation?
A) Uncoordinated movements, altered sense of smell
B) Decreased attention span, difficulty problem solving
C) Apathy, depression
D) Rapid mood changes, anxiety
B) Decreased attention span, difficulty problem solving
Cognitive responses to sensory deprivation include an inability to control thoughts, decreased attention span, and
difficulty with memory, problem solving, and task performance.
A client admitted to the hospital for major surgery is at risk for what type of sensory alteration? A) Sensory deprivation B) Sensory deficits C) Sensory overload D) Sensory stimulation
C) Sensory overload
Sensory overload is the condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli. In some clients, especially those coming from a quiet environment
with unvarying stimuli, the experience of being hospitalized results in sensory overload.
What intervention is recommended to reduce sensory stimulation for infants in the neonatal ICU? A) Use bright lights B) Use limited light C) Play loud music D) Avoid touch
B) Use limited light
Research has found that the neonatal ICU is a source of inappropriate sensorystimulation. To facilitate developmentally
supportive care, it is recommended that medically fragile infants have limited light, visual, and vestibular stimulation to
simulate being in the womb
A client tells his nurse that he has difficulty hearing related to working in a loud factory setting for 15 years. What is the term for this condition? A) Sensory deficit B) Sensory deprivation C) Sensory overload D) Sensory stimulation
A) Sensory deficit
Impaired or absent functioning in one or more senses is termed sensory deficit
A nurse assesses a mother who rocks and cuddles her newborn son. What sense is the mother stimulating? A) Auditory B) Kinesthetic C) Visual D) Gustatory
B) Kinesthetic
Different types of sensory stimulation are needed for growth as sensory receptors, organs, and the nervous system mature. Appropriate stimulation includes soothing, holding, rocking and changes of position (tactile and kinesthetic sensations), singing and being talked to (auditory sensations), and changing patterns of light and shade, such as through
the use of mobiles and bright objects (visual sensations).
Is it important for a nurse to consider a client’s culture when providing physical care?
A) Yes, culture dictates the amount of sensory stimulation considered normal.
B) Yes, the nurse’s culture and the client’s culture are often different.
C) No, the nurse must provide needed physical care to all clients.
D) No, the nurse is not required to consider culture when providing care.
A) Yes, culture dictates the amount of sensory stimulation considered normal.
An individual’s culture may dictate the amount of sensory stimulation considered normal. Ethnicity, religion, income,
and subgroup norms within a culture all influence the amount of sensory stimulation sought by an individual and
considered normal.
A nurse is assessing a client on the first day after major abdominal surgery. Which of the following internal stimuli
would be increased and affect client responses?
A) Lights and noise
B) Visitors and caregivers
C) Intravenous lines, pain
D) Ambulating, coughing
C) Intravenous lines, pain
When assessing a client at risk for increased sensory stimulation, it is important to consider both internal and external stimuli that may cause sensory overload. Invasive treatments, such as intravenous lines, and pain are internal stimuli.
A nurse assessing older adults in a long-term care facility is aware that which of the following may result in sensory alterations for these clients? A) Constipation B) Anorexia C) Dry skin D) Presbyopia
D) Presbyopia
The senses of vision, hearing, and touch decline with aging. Common sensory problems include presbyopia, a condition of aging in which decreased elasticity of the lens of the eye hinders accommodation to close vision.
A client has an abrupt onset of a cluster of global changes in attention, cognition, and level of consciousness. What
would be the most appropriate nursing diagnosis?
A) Acute Confusion
B) Chronic Confusion
C) Impaired Memory
D) Disturbed Sensory Perception
A) Acute Confusion
The nursing diagnosis Acute Confusion is most appropriate. The definition of this diagnosis is “the abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or sleep–wake cycles.”
A home care client has both visual and hearing deficits. Although all of the following are important, what would be a
high priority concern when planning and implementing care?
A) Nutrition
B) Comfort
C) Safety
D) Communication
C) Safety
Safety is always a special concern for clients with sensory alterations. The nurse must ensure that the client’s environment is as free of danger as possible, and assist the client in developing new self-care behaviors to compensate
for sensory impairments.
A nurse asks the mother of a hospitalized client age 2 years to bring in his favorite blanket or stuffed animal. What sense
is the nurse trying to stimulate with this intervention?
A) Gustatory
B) Visual
C) Tactile
D) Auditory
C) Tactile
The different texture of the blanket/stuffed animal stimulates the tactile sense (sense of touch)
Which of the following nonpharmacologic, independent nursing interventions may be used to promote relaxation
without also causing sensory overload?
A) Talking with the client
B) Playing music the client chooses
C) Watching talk shows the nurse chooses
D) Watching television reality shows that visitors choose
B) Playing music the client chooses
Music therapy has been found to be beneficial in reducing the stress response and promoting nonpharmacologic induced
relaxation. It is important to choose music the client prefers
A community health nurse is conducting a seminar on vision self-care. What might be one topic included in the
education plan?
A) Wear sunglasses when working outside.
B) Close the eyes when working with chemicals.
C) Use over-the-counter eye drops when necessary.
D) When using aerosol sprays, spray toward self
A) Wear sunglasses when working outside.
One suggestion for teaching self-care behaviors related to maintaining vision and preventing blindness is to wear sunglasses when working outdoors. This will help avoid damage from ultraviolet rays
A nurse is educating a lawn-care worker on the risk of hearing loss. What might be recommended?
A) “Listen to loud music with earphones while mowing.”
B) “Just ignore the noise; you are too young for damage.”
C) “Wear earplugs while using lawn equipment.”
D) “Clean your ears with cotton-tipped applicators daily.”
C) “Wear earplugs while using lawn equipment.”
Health education for reducing the risk of hearing loss, which may begin at any age, includes wearing earplugs when
using loud equipment.
A nurse is making a home care visit to a client with a hearing deficit. What can she do to facilitate communication with the client?
A) Ask for permission to turn off the television set during the visit.
B) Talk in a loud tone of voice at all times during the visit.
C) Use written communication rather than verbal communication.
D) Reduce the time spent with the client to decrease frustration.
A) Ask for permission to turn off the television set during the visit.
One way in which communication with a client with a hearing deficit can be facilitated is to decrease background noises
(as from a television)
A nurse is caring for a person who is delusional. What is important for the nurse to do while communicating with the
client?
A) Touch the client gently while talking.
B) Avoid arguing about erroneous statements.
C) Reinforce reality for delusional statements.
D) Maintain eye contact at all times.
C) Reinforce reality for delusional statements.
Nursing interventions to be used when communicating with a confused client include reinforcing reality if the client is delusional.
A nurse is caring for a client who is unconscious. Which of the following is a recommended guideline for
communication with this client?
A) Do not assume the person can hear you.
B) Keep environmental noise level high to stimulate the client.
C) Be careful what is said in front of the client as he or she might hear you.
D) Touch the person before speaking to them
C) Be careful what is said in front of the client as he or she might hear you.
The following are recommended guidelines when communicating with a client who is unconscious: be careful what is said in front of the client as he or she might hear you, assume the person can hear you, keep environmental noise level low, and speak to the person before touching him or her.
During a client assessment, the nurse has the client close his eyes. She then places her finger on his right thigh. She asks the client where he is being touched and he answers “my right thigh.” This is an example of which sense? A) Auditory B) Visual C) Kinesthetic D) Olfactory
C) Kinesthetic
The kinesthetic sense influences the awareness of placement and action of body parts.
When a new mother asks the nurse whether her newborn infant can see her, the best response by the nurse is to tell the mother that her infant … A) cannot see for 2 weeks of age B) can differentiate objects only C) can differentiate colors only D) can see light and dark patterns
D) can see light and dark patterns
Newborns see only gross patterns of light and dark or bright colors. As they grow, vision becomes more discriminating
A client in the intensive care unit will experience less sensory overload in which of the following situations?
A) If a clock displays date, time, AM/PM
B) If the nurse silences the alarms
C) If the nurse provides touch every hour
D) If the family visits at all times
A) If a clock displays date, time, AM/PM
Disorientation can occur when expected day/night differences in levels of general activity are lost. To reduce such disorientation, provide a clock displaying a clear distinction of AM/PM time, day, and date. Silencing the alarms could
compromise the client’s care.
A client with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the client experiencing? A) Physical B) Psychological C) Sensory deficits D) Sociocultural
C) Sensory deficits
Sensory deficits in vision and hearing interfere with one’s ability to interact with other people and with the environment.
Which of the following are conditions that must be met for a person to receive the necessary data to experience the world? Select all that apply.
A) A stimulus must be present.
B) A receptor or sense organ must receive the stimulus and convert it to a nerve impulse.
C) The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain.
D) The stimulus must be recognized by the cardiovascular system and sent to the brain.
E) The person must physically and mentally recognize the stimulus and accept or reject it in the brain.
F) A particular area in the brain must receive and translate the impulse into a sensation
A) A stimulus must be present.
B) A receptor or sense organ must receive the stimulus and convert it to a nerve impulse.
C) The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain.
F) A particular area in the brain must receive and translate the impulse into a sensation
For a person to receive the necessary data to experience the world, four conditions must be met: (1) a stimulus—an agent, act, or other influence capable of initiating a response by the nervous system—must be present. (2) A receptor or
sense organ must receive the stimulus and convert it to a nerve impulse. (3) The nerve impulse must be conducted along a nervous pathway from the receptor or sense organ to the brain. (4) A particular area in the brain must receive and
translate the impulse into a sensation
The nurse is caring for a client who suffered a stroke three days ago, and is assessing the client’s state of arousal. The nurse knows that the part of the body responsible for a person being alert or aroused is which of the following? A) Reticular activating system B) Renin-angiotensin-aldosterone system C) Cranial nerves D) Adrenal glands
A) Reticular activating system
The reticular activating system (RAS) mediates arousal. The adrenal glands are endocrine glands that have many functions, but do not control arousal or alertness. The renin-angiotensin-aldosterone system has to do with fluid balance and blood pressure. The cranial nerves have a role in many of the body’s abilities, but not arousal.
During the neurological assessment, the nurse asks the client if she has any problems with her sense of smell. The client relates that she lives near a factory that emits an obnoxious odor, but that she no longer notices the smell. The nurse tells Joan that this phenomenon is normal and is called which of the following? A) Tolerance B) Adaptation C) Acceptance D) Adjustment
B) Adaptation
The body quickly adapts to constant stimuli. In addition, the repeated stimulus of a continuing noise, such as city traffic, or a noxious odor eventually goes unnoticed. This phenomenon is termed “adaptation”
The nurse is caring for client 82 years of age who is struggling to adapt to hearing loss as he ages. The nurse performs
which of the following interventions to assist the client in adapting to this sensory deficit? Choose all that apply.
A) Make sure he wears his hearing aid.
B) Speak in a lower tone of voice.
C) Speak so he can observe your lip movement.
D) Keep his environment clear of clutter.
E) Orient to person, place, and time frequently
A) Make sure he wears his hearing aid.
B) Speak in a lower tone of voice.
C) Speak so he can observe your lip movement.
Speaking in low tones and making sure he can see your lip movement will assist the client in hearing and understanding better, as will wearing his hearing aid. Keeping his room free of clutter is nice, but will not assist his hearing.
Reorienting will not help to improve the client’s hearing.
The nurse is working in a clinic and sees a resident of a long-term-care facility, age 82 years, who has come in to be
checked by her physician. The caregiver, who accompanies her, reports that the client has been displaying the following: drowsiness, excessive sleeping, decreased attention span, irritability, and signs of depression. The client’s daughter and family, who usually visit her, moved away from the area six weeks ago due to the husband’s job. You suspect which of
the following problems?
A) Sensory deprivation
B) Disturbed sensory perception
C) Residential psychosis
D) Locked-in syndrome
A) Sensory deprivation
Sensory deprivation results when a person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. A client confined to bed rest may receive many fewer stimuli, whereas one undergoing multiple diagnostic tests may receive a greater-than-normal level of sensory input. These and other typical experiences are likely to result in disturbed sensory perceptions experienced by the client. Locked-in syndrome is a state of full consciousness;
sleep–wake cycles are present; quadriplegic, auditory and visual function are preserved; emotion is preserved. Residential psychosis is not a real condition.
