Chapter 44 Sensory Functioning and Neuro Assessment

Question 1

describe the four conditions necessary that must be met in each sensory

Answer 1

stimulus: an agent, act or other influence capable of initiating a response by the nervous system.
A receptor :must receive the stimulus and convert it to a nerve impulse.
A nerve impulse :must be conducted along a nervous pathway from the receptor or sense organ to the brain
sensation:

Question 2

The body’s basic orienting systems

Answer 2

kinesthetic and visceral senses

Question 3

awareness of positioning of body parts and body movement; visceral pertains (to inner organs)

Answer 3

kinesthesia

Question 4

The sensory experience consists of

Answer 4

reception: the process of receiving data about the external or internal environment through the senses; visual (vision) auditory(hearing) smell (olfactory), taste (gustatory).
perception: the conscious process of selecting, organizing, and interpreting data from the senses into meaningful information.

Question 5

The conscious process of selecting, organizing, and interpreting data from the senses into meaningful information

Answer 5

sensory perception

Question 6

The process of receiving data about the external or internal environment through the senses; vision,hearing, smell, tast, and touch (tactile)

Answer 6

Sensory reception

Question 7

explain the role of the reticular activating system in sensory experience

Answer 7

The RAS monitor and regulate incoming sensory stimuli, thus maintaining, enhancing or inhibiting cortical arousal.

Question 8

Sensoristasis

Answer 8

The optimal arousal state of the RAS

Question 9

Patient unable to rest because of machine beeping

Answer 9

The nurse would incorporate knowledge of sensory reception and perception. Patient is experiencing a continuous and large amount of auditory( beeping machine) visual( light in room and machine), tactile (being touched) and internal stimuli (pain, discomfort).

Question 10

full consciousness; sleep-wake cycles present; quadriplegic, auditory and visual function preserved; emotion preserved.

Answer 10

Locked-in-syndrome

Question 11

somnolence

Answer 11

extreme drowsiness, but will respond normally to stimuli

Question 12

An unconscious states where a person can be aroused by extreme and/or repeated stimuli

Answer 12

stupor

Question 13

vegetative state

Answer 13

cannot be aroused, sleep-wake cycles, postures or withdraws to noxious stimuli, occasional nonpurposeful movement, random smiling or grimacing.

Question 14

A person experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless.

Answer 14

sensory deprivation

Question 15

Factors pacing a patient at high risk for sensory deprivation

Answer 15

environment with decreased or monotonous stimuli (patients on bed rest or in isolation).
impaired ability to receive environment stimuli (patient with vision hearing or tactile stimulation)
inability to process environmental stimuli (patients with spinal cord injuries or brain damage, confused/disoriented or drugs affecting the CNS).

Question 16

Perceptual responses

Answer 16

result from inaccurate perception of sights, sounds, tastes, smells, body position, coordination and equilibrium (day-dreams, hallucinations).

Question 17

inability to control the direction of thought content. Difficult with memory, problem solving, and task performance.

Answer 17

cognitive responses

Question 18

Typically manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. Rapid mood changes also may occur.

Answer 18

emotional responses

Question 19

condition that results when a person experiences so much sensory stimuli that the brain is unable to either respond meaningfully or ignore the stimuli.

Answer 19

sensory overload

Question 20

factors that influence sensory overload.

Answer 20

age, culture, personality and lifestyle

Question 21

sensory perception is influenced by

Answer 21

intensity, size, change or representation of stimuli, past experiences, knowledge, and attitudes.

Question 22

patient in ICU exhibiting transient episodes of acute confusion. NI

Answer 22

be alert for factors contributing to sensory overload, such as bright lights, noises from the monitoring devices, frequent examinations. Also possible factors contributing to sensory deprivation (reduced auditory stimuli), restricted interacting with the environment.

Question 23

how can the nurse help reduce disturbances in sensory perception

Answer 23

being sensitive to how visual stimuli, noise, touch are stimulating the patient.
paying attention to the patient’s need for privacy and for social interaction.

Question 24

what is the max point for the glasgow coma scale

Answer 24

15

Question 25

a patient is considered to be in a coma when the Glasgow coma scale is

Answer 25

less than 7

Question 26

impaired or absent functioning in one or more sense

Answer 26

sensory deficit

Question 27

Examples of sensory deficit

Answer 27

impaired sight and hearing, altered taste, numbness, paralysis, tactile perception and impaired kinesthetic sense

Question 28

NI visual stimulation

Answer 28

colorful sheets, pajamas, robes, uniform tops for the nurse, face to face contact, clocks,calendars, wristwatches, flowers, greeting cards.

Question 29

NI auditory stimulation

Answer 29

call person by name, use conversation that communicates caring as well as orients patient, reading to the patient, television, radio, ipod.

Question 30

IN gustatory and olfactory stimulation

Answer 30

oral hygiene and properly fitting dentures, food of different textures, colors, temperatures served.
smelling food before eating and recalling pleasurable aromas from the past.
seasoning foods or having favorite foods brought from home (order)

Question 31

NI tactile stimulation

Answer 31

backrubs and foot soaks, turning and repositioning, passive ROM, hair brushing, combing, washing, hugs, and touching or arms or shoulders.

Question 32

NI cognitive input

Answer 32

orient patient to environment
encourage patient participation in self-care
discuss current events or patient’s occupation, hobbies or interests.
reinforce reality without arguing.

Question 33

NI emotional imput

Answer 33

encourage patient to share fears, concerns and perceptions
reassure patient that illusions and misperceptions do occur with sensory deprivation.
incorporate culturally assistive, supportive, facilitative acts into care.

Question 34

factors affecting states of awareness

Answer 34

inadequate blood flow
altered nutrition and metabolism 
fluid and electrolyte imbalances
infectious processes
inadequate sleep and rest
inability to organize incoming stimuli
dementia
sensory alterations and sensory deficits

Question 35

NI for patient with sensory overload

Answer 35

provide a consistent, predictable pattern of stimulation to help patient develop a sense of control over the environment.
offer simple explanations before procedures, test and examinations.
establish a schedule with the patient for routine care.
speak calmly and move slowly, communicate confidence.
explore with the patient what stimuli are most distressing and develop a plan to reduce or eliminate.
be careful not to cause sensory deprivation.
identify and, whenever possible, eliminate culturally inappropriate stimuli

Question 36

The deteriorating of nerves and structures within the inner ear. occurs as an individual ages.

Answer 36

Presbycusis

Question 37

factors that place a patient at high risk for sensory deprivation

Answer 37

decrease environmental stimuli
impaired ability to receive environmental stimuli
inability to process environmental stimuli

Question 38

manifestations of sensory deprivation

Answer 38

physical behaviors
escape behaviors
change in perception
changes in cognitive behaviors
changes in affective behaviors

Question 39

Effects of sensory deprivation

Answer 39

perceptual responses
cognitive responses
emotional responses

Question 40

sensory overload

Answer 40

increase internal stimuli, external stimuli

inability perceptually to disregard or selectively ignore some stimuli

Question 41

communicating with unconscious patient

Answer 41

be careful what is said in their presence (hearing is the last sense lost).
assume the person can hear you.
speak to the person before touching.
keep surrounding noises down to a minimum.

Question 42

the term used to describe the sense, at a subconscious level, or the movements and position of the body and especially its limbs, independent of vision

Answer 42

proprioception

Question 43

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

Answer 43

stereognosis

Question 44

making up answers unrelated to facts

Answer 44

confabulation

Question 45

involuntary repetitions of words spoken by another person

Answer 45

Echolalia

Question 46

Mini-mental state Exam (MMSE)

Answer 46

use to diagnose dementia or delirium
tests orientations,short-term memory and attention, ability to perform calculations, language and construction

cannot be used if patient cannot read, write or speak english

Question 47

loss or impairment of the power to use or comprehend words usually resulting from brain damage

Answer 47

Aphasia

Question 48

loss of or deficiency in the power to use or understand language as a result of injury to a disease or the brain

Answer 48

dysphasia

Question 49

The patient knows what to say, yet has difficulty communicating

Answer 49

Expressive aphasia

Question 50

patient have difficulty understanding words

Answer 50

receptive aphasia

Question 51

global aphasia

Answer 51

difficulty with using and understanding words