NCLEX Questions - Sensory Perception/ Sleep Flashcards
Which statement indicates the client needs a sensory aid in the home?
a. “I tripped over that throw rug again.”
b. “I can’t hear the doorbell.”
c. “My eyesight is good if I wear my glasses.”
d. “I can hear the TV if I turn it up high.”
b
A hospitalized client is disoriented and believes she is in a train station. Which response from the
nurse is the most appropriate?
a. “You won’t be getting a bath at the train station.”
b. “Let’s finish your bath before the train arrives.”
c. “Don’t you know where you are?”
d. “It may seem like a train station sometimes, but this is Valley Hospital.”
d
The client with impaired vision is admitted to the hospital. Which interventions are most
appropriate to meet the client’s needs? Select all that apply.
a. Identify yourself by name.
b. Decrease background noise before speaking.
c. Stay in the client’s field of vision.
d. Explain the sounds of the environment.
e. Keep your voice at the same level throughout the conversation.
a,c,e
The client is exhibiting signs and symptoms of acute confusion/delirium. Which strategy should the
nurse implement to promote a therapeutic environment?
a. Keep lights in the room dimmed during the day to decrease stimulation.
b. Keep the environmental noise level high to increase stimulation.
c. Keep the room organized and clean.
d. Use restraints for client safety.
c
A client diagnosed with delirium becomes disoriented and confused at night. Which intervention
should the nurse implement initially?
a. Move the client next to the nurses’ station.
b. Use an indirect light source and turn off the television.
c. Keep the television and a soft light on during the night.
d. Play soft music during the night, and maintain a well-lit room.
b
The client is at risk for sensory deprivation. Which of the following clinical signs would the nurse
observe? Select all that apply.
a. Sleeplessness
b. Decreased attention span
c. Irritability
d. Excessive sleeping
e. Crying, depression
b,d,e
Which client is at greatest risk of experiencing sensory overload?
a. A 40-year-old client in isolation with no family
b. A 28-year-old quadriplegic client in a private
room
c. A 16-year-old listening to loud music
d. An 80-year-old client admitted for emergency
surgery
d
An alert 80-year-old client is transferred to a
long-term care facility. On the second night he
becomes confused and agitated. What is the
most appropriate nursing diagnosis?
a. Chronic Confusion
b. Impaired Memory
c. Disturbed Sensory Perception
d. Disturbed Thought Processes
c
The nursing diagnosis Risk for Impaired Skin
Integrity related to sensory-perception
disturbance would best fit a client who:
a. Cut a foot by stepping on broken glass.
b. Uses a wheelchair due to paraplegia.
c. Wears glasses because of poor vision.
d. Is legally blind and smokes in bed.
b
Which statement indicates the client needs a sensory aid in the home?
a. “I tripped over that throw rug again.”
b. “I can’t hear the doorbell.”
c. “My eyesight is good if I wear my glasses.”
d. “I can hear the TV if I turn it up high.”
b
A hospitalized client is disoriented and believes
she is in a train station. Which response from
the nurse is the most appropriate?
a. “You wouldn’t be getting a bath at the train
station.”
b. “Let’s finish your bath before the train arrives.”
c. “Don’t you know where you are?”
d. “It may seem like a train station sometimes,
but this is Valley Hospital.”
d
The nurse is performing an assessment on an older client who is having difficulty sleeping at night.
Which statement, if made by the client, indicates that teaching about improving sleep is necessary?
a. “I swim three times a week.”
b. “I have stopped smoking cigars.”
c. “I drink hot chocolate before bedtime.”
d. “I read 40 minutes before bedtime.”
c
A patient is being admitted to the hospital and the nurse is performing a complete assessment.
Which is the most therapeutic question the nurse can ask about the quality of the patient’s sleep?
a. “How would you describe your sleep?”
b. “Do you consider your sleep to be restless or restful?”
c. “Is the number of hours you sleep at night good for you?”
d. “Does your bed partner complain about your sleep behaviors?”
a
A patient is having difficulty sleeping and may be experiencing shortened non-rapid eye movement
(NREM) sleep. Which patient assessments support this conclusion? Select all that apply.
a. Decreased pain tolerance
b. Inability to concentrate
c. Excessive sleepiness
d. Irritability
e. Confusion
a,c
An older female adult explains to the nurse that she has insomnia. The nurse interviews the patient
and her husband and reviews the patient’s medication reconciliation form. Which factors does the
nurse conclude are associated with the patient’s insomnia? Select all that apply.
a. Metformin
b. Older adult
c. Female gender
d. Alcohol intake
e. Diphenhydramine
f. Catnaps during the dayb,c,d
b,c,d
