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A nurse is administering a vaccine to a 4-year-old child who is visually impaired. After
the needle enters the arm, the child says, “Ow, that was sharp!” The nurse knows that the ability to
recognize and interpret stimuli is known as
Perception.
What is the involuntary motion of retracting the body from painful stimuli?
Reaction
A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to
presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit?
The patient turns one ear toward the nurse during conversation.
The nurse would be most concerned about the risk of malnutrition for a patient with
which sensory deficit?
xerostomia
Which of the following sensory changes are normal with aging?
Impaired night vision
A nurse is caring for an elderly patient who was in a motor vehicle accident because he
thought the stop light was green. The patient asks the nurse if he should no longer drive. Which
response by the nurse is most therapeutic?
“No, as you age, you lose the ability to see colors. You need to think about
stoplights in a new way. If the top is illuminated, it means stop, and if the bottom is
illuminated, it means go.”
A nurse is caring for a patient who recently had a stroke and is going to be discharged at
the end of the week. The nurse notices that the patient is having difficulty with attempting to eat his
meal and is becoming tearful. The nurse includes which intervention in the patient’s plan of care?
Teach the patient about special devices used to assist patients with eating meals.
Which nursing diagnosis addresses psychological concerns for a patient with both
hearing and visual sensory impairment?
Social isolation
A patient informs the nurse that she often becomes nauseated when riding in motor
vehicles. The nurse knows that this is related to which sensory deficit?
Balance deficit
A home health nurse is assembling a puzzle with an elderly patient and notices that the
patient is having difficulty connecting two puzzle pieces. The nurse knows that this is most likely
related to which aspect of sensory deprivation?
Perceptual
Which assessment question should the nurse ask to best understand how visual
alterations are affecting the patient’s self-care ability?
“Are you able to prepare a meal or write a check?”
Which nursing assessment best measures cognitive functioning?
Administer a Mini-Mental Status Exam (MMSE).
The nurse would utilize the Snellen chart for assessment of which patient?
A patient who frequently reports the incorrect time from the clock across the room
A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The
patient is becoming malnourished because nothing tastes good. Which recommendation by the
nurse would be most appropriate for this patient?
“Rinse your mouth several times a day to hydrate your taste buds.”
The nurse is creating a plan of care for a patient with glaucoma. Which nursing
diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for
injury?
Risk for falls
The nurse is caring for a patient who is having difficulty understanding written and
spoken word? The nurse suspects the patient has _____ aphasia.
Receptive
The nurse is caring for a patient with conductive hearing loss resulting from prolonged
cerumen impaction. Which intervention by the nurse is most important in establishing effective
communication with the patient?
Speaking with hands, face, and expressions
The home health nurse is caring for a patient with a tactile deficit; the nurse is
concerned about injury related to inability to feel harmful stimuli. The nurse evaluates that the
patient is able to safely care for himself when the patient demonstrates which action?
Places colored stickers on faucet handles to indicate temperature and keeps a
thermometer near the tub
Often blindness occurs during childhood. Which health preventative measure is most
appropriate to prevent vision impairment?
Include rubella and syphilis screening in the preconception care plan.
The nurse is caring for a patient in acute respiratory distress. The patient has multiple
monitoring systems on that constantly beep and make noise. The patient is becoming agitated and
frustrated over inability to sleep. Which action by the nurse is most appropriate for this patient?
Provide the patient with earplugs.
The nurse is caring for a patient with expressive aphasia from a traumatic brain injury.
Which desired outcome should be included in the plan of care?
Patient will communicate nonverbally.
The nurse is aware that which patient is most at risk for sensory deprivation?
A patient on the unit with tuberculosis on airborne precautions
What nursing action can the nurse implement to comfort an elderly patient with
sensory deprivation to improve meaningful stimuli?
Offering the patient a back rub
The nurse is caring for a patient who is a well-known surgeon at the hospital. Because
of his status, all the hospital’s physicians want to be sure to pay him a visit. The nurse notices the
patient becoming more agitated and withdrawn with each group of visitors. The nurse asks the
patient if he would like a “Do not disturb” sign placed on the door. A few hours later, the nurse
notices a physician who is not involved in the patient’s care attempting to enter the room. Which
response by the nurse is most appropriate?
Firmly explaining that the patient does not wish to have visitors at this time, so do
not enter the room
The nurse is caring for a patient who is recovering from a traumatic brain injury and
frequently becomes disoriented to everything except her location. Which nursing intervention
would be effective in orienting a patient with neurological deficit?
Keeping a day-by-day calendar at the patient’s bedside and having the patient
manage it
A nurse is establishing a relationship with the patient who is visually impaired. Which
is the most appropriate method to teach the patient how to contact the nurse for assistance?
Place a raised Braille sticker on the call button, and instruct the patient to press for
assistance.
The nurse is developing a plan of care for a patient who is having a prosthetic eye
placed. Which nursing diagnosis related to patient safety is the priority for the nurse to include in
the plan of care?
risk for injury
A nurse is caring for a patient who is experiencing vertigo. Which nursing intervention
would assist the patient in controlling the vertigo?
Avoiding riding in vehicles and making sudden motions
A nurse is caring for a patient with right-sided weakness following a stroke. Which
nursing action would be least effective in promoting positive adaptation of the patient’s sensory
deficit?
Completing sentences that the patient cannot finish
