Sensory Perception Flashcards
Unit 1
What is the Difference between sensory deficit, overload, and deprivation?
Sensory deficit is A deficit in the expected function of one or more of the five senses.
Sensory deprivation is A reduction in or absence of stimuli to one or more of the five senses.
Sensory overload is Receiving stimuli at a rate and intensity beyond the brain’s ability to process the stimuli in a meaningful way.
Cranial Nerves
Nerve
Number
Function
Test for Proper Function
Olfactory
I
Sensory to nose for smell
Ask client to identify specific smells, such as coffee or peppermint, testing each nostril separately.
Optic
II
Sensory to eye for vision
Test visual acuity using Snellen chart or by having client read printed material.
Oculomotor
III
Motor to eye
Check extraocular movements by assessing the 6 directions of gaze.
Check pupillary reaction to light and accommodation.
Trochlear
IV
Motor to eye
Assess the 6 directions of gaze.
Trigeminal
V
Sensory to face
Motor to muscles of jaw
Assess corneal reflex.
Palpate the masseter muscles at the temple while client clenches jaw.
Check sensation by lightly touching over the face with a cotton ball.
Abducens
VI
Motor to eye
Assess the 6 directions of gaze.
Facial
VII
Sensory to tongue for taste
Motor to face for expression
Monitor for symmetry of the face when the client smiles and raises/lowers eyebrows.
Check perception of sweet and salty tastes on the front of the tongue.
Vestibulocochlear (Auditory)
VIII
Sensory to ear for hearing and balance
Whisper a word 2 to 3 cm away from one ear while client occludes the other ear. Check both ears.
Observe the client’s balance as they walk.
Glossopharyngeal
IX
Sensory to tongue for taste
Motor to pharynx (throat)
Check perception of sweet and sour tastes on the back of the tongue.
Use a tongue blade to check the gag reflex.
Assess the ability to swallow.
Vagus
X
Sensory to pharynx
Motor to vocal cords
Parasympathetic innervation to heart lungs, abdominal organs
Have client say “ah” and observe palate and pharynx for movement.
Listen for hoarseness of voice.
Assess pulse, bowel sounds.
Accessory
XI
Motor to muscles of neck
Observe ability to turn head side to side.
Monitor client’s ability to shrug shoulders against resistance from examiner’s hands.
Hypoglossal
XII
Motor to tongue
Ask client to stick tongue out, observe if midline;
Assess ability to move tongue side to side.
What are the conditions that interfere with the client’s ability to process sensory input?
A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make?
“SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin.”
The inability to see faraway objects clearly is what
myopia or nearsightedness
The inability to see nearby objects clearly is known as what?
hyperopia or farsightedness
What is astigmatism?
A defect in the eye making objects nearby and faraway look blurry or distorted.
What is presbyopia?
Age-related farsightedness, or a gradual decrease in the ability to clearly see nearby
What is the leading cause of blindness in adults?
Diabetic retinopathy
What is cataracts?
Clouding of the lens of the eye that causes the vision to be blurry, hazy or less colorful.
What is glaucoma?
An increase in intraocular pressure due to the buildup of fluid; that causes compression of the optic nerve.
An irreversible degeneration of the macula that leads to a loss of central vision as clients age is known as what?
Macular degeneration
What is Tinnitus?
Ringing or A sound that other people usually cannot hear.
What is sensorineural hearing loss (SNHL)?
The most common type of hearing loss; occurs from the problems either in the inner ear or the auditory nerve
Loss of hearing that occurs due to aging is
Presbycusis
What causes ototoxicity and what does it do?
Some medications; Causing damage to or dysfunction of the cochlea or vestibule.
A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic?
Loop diuretics is correct. Some loop diuretics, such as furosemide, are ototoxic medications.
NSAIDs is correct. Some ototoxic medications are nonsteroidal anti-inflammatory drugs (NSAIDs).
Aminoglycoside antibiotics is correct. Aminoglycoside and macrolide antibiotics can be ototoxic. This includes medication such as streptomycin, gentamicin, and tobramycin.
What is conductive hearing loss?
Inability of sound to travel from the outer ear to the eardrum and middle ear.
Which of the following factors are a potential cause of conductive hearing loss? Select all that apply
Trauma to the outer ear is correct. Trauma to either the middle or outer ear can cause hearing loss.
Inflammation is correct. Inflammation causes the canal to narrow, which reduces the ability of sound to travel from the outer to inner ear.
Cerumen buildup is correct. Cerumen buildup in the ear canal causes blockage, reducing the ability of sound to travel to the inner ear structures.
Otitis media is correct. Otitis media causes inflammation or an accumulation of fluid in the ear and can result in conductive hearing loss.
What is Otitis media?
Inflammation in or the build up of fluid in the middle ear.
Abnormal growth of bone in the middle ear that can cause conductive hearing loss is known as
otosclerosis
What is cerebration?
The act of thinking, or using one’s mind
Aphasia
A disorder that affects a client’s ability to articulate and understand speech and written language
Expressive VS Comprehensive VS Global Aphasia
Expressive aphasia
Also known as Broca’s or nonfluent aphasia and is due to damage to the frontal lobe of the brain. A client who has Broca’s aphasia may understand speech but will be unable to speak the words they want to say.
Comprehensive aphasia
Also called Wernicke’s or fluent aphasia, caused by damage to the temporal lobe of the brain. A client who has Wernicke’s aphasia speaks in long sentences that have no meaning and often include unnecessary and made-up words.
Global aphasia
Severe impairments in communication caused by significant damage to various language areas of the brain. Clients who have this type of aphasia have poor comprehension of language and may be unable to form words or sentences.
Tactile hypersensitivity VS defensiveness VS hyposensitivity
tactile hypersensitivity
Being overly sensitive to tactile stimulation.
tactile defensiveness
A severe sensitivity to touch that most people would find acceptable that often causes physical pain
tactile hyposensitivity
Under-responsiveness to tactile stimulation.
Peripheral neuropathy
Conditions that occur when nerves in the central nervous system become damaged resulting in numbness, pain, and weakness to the extremities.
Neuropathy due to nerve damage of an unknown cause is
idiopathic neuropathy
What is diabetic neuropathy?
Nerve damage and loss of sensation in the lower extremities due to to the small blood vessels supplying blood to the nerves.
What are gustatory cells?
Taste cells that contain specific receptors that allow for differentiation between sweet, sour, bitter, salty, or savory flavors.
Specialized cells inside the nose that have an odor receptor and create the ability to smell are the
olfactory sensory neurons
What is phantom taste perception?
A persistent, foul taste when the mouth is empty
A decreased ability to taste?
Hypogeusia
The inability to taste anything is?
ageusia
What is Dysgeusia?
A condition in which a foul, salty, or metallic taste occurs in the mouth.
The inability to smell anything is
Anosmia
What abilities to taste can decrease with age?
Sour, Bitter, and Salty
A nurse is reviewing the medical record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia?
A. Gastroesophageal reflux disease
B. Herniated lumbar disc
C. Wernicke’s aphasia
D. Alzheimer’s disease
Alzheimer’s disease
Rationale
Neurologic conditions can lead to anosmia, or a loss of the sense of smell. This includes conditions such as Alzheimer’s disease or Parkinson’s disease.
What is the disorder where a nonexistent smell is perceived?
Phantosmia
Hyposmia is
A reduction in the ability to perceive odors
Parosmia is
A distortion in smells, such as when a previously pleasant smell becomes unpleasant.
What are the factors that affect a patient’s sensory-perceptual processes?
Age Considerations
Medications: Ototoxic, Taste alterations, and Perception
Cognitive Disorientation: Dementia and Delirium
What is Dementia?
A cognitive disorder that can impair communication ability due to language and memory changes.
What is delirium?
A syndrome that has a rapid onset and causes a disturbance in mental ability resulting in confused thinking and reduced awareness of the environment.
A nurse is assessing a client who has delirium. Which of the following manifestations can the nurse expect to see?
Difficulty maintaining attention is correct. Difficulty maintaining attention and fluctuating consciousness are expected manifestations of delirium.
Agitation is correct. Agitation and mood swings are expected manifestations of delirium.
Hallucinations is correct. Hallucinations are an expected manifestation of delirium. Hallucinations and other manifestations resolve once the cause of the delirium is effectively treated.
Rambling speech is correct. Rambling speech and difficulty speaking are expected manifestations of delirium.
Which tests are used to diagnose sensory perceptual impairment?
Vision tests, Hearing tests, and EMG and Tactile Testing
What is a slit lamp and what is it used for?
A microscope that contains a bright light used to examine the structures of the eye.
What is fluorescein angiography?
Injection of dye into a peripheral vein, followed by taking photos of the vessels in the eye as the dye flows through them.
What is an Amsler grid? What outcome does it determine?
A test used to assess macular degeneration whereby a client is shown a grid made of lines, like graph paper, and asked if the lines look straight or wavy, or if any section of the grid is missing.
A hearing test that is performed with a tuning fork that is vibrated and placed against the mastoid bone and the client is asked to identify when they are unable to hear the sound. The tuning fork is then moved 1 to 2 cm away from the ear and the client indicates if they can still hear the sound. Which test is this?
The Rinne test
A hearing test whereby a client wears earphones and various sounds at different decibel levels are played in each ear. The client identifies when they can hear each sound.
Which test is this?
The audiometer test
What is the Bone oscillator test?
A test that determines how effectively vibrations are transmitted through the ossicles
What is the auditory brainstem response (ABR) test
A hearing test whereby small electrodes are placed on the scalp to measure the brain s electrical activity in response to the sound of clicking noises.
The test whereby a small probe is placed in the auditory canal, sounds are emitted, and the resulting echo is recorded, assessing the response of the inner ear. Is which test?
otoacoustic emissions (OAE) test
Electromyography (EMG) tests for by doing what?
nerve damage whereby very small needles are inserted into a muscle and a machine records the electrical activity in the muscle.
A nurse is preparing an inservice for a group of staff members about types of test used to diagnose sensory impairments. Which of the following information should the nurse include?
A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.
What are the nursing interventions to facilitate or maintain a client’s sensory perception?
Vision
Hearing
Speech
Touch
Olfactory/Taste
What is sensory deficit?
A deficit in the expected function of one or more of their five senses
Laryngectomy is
The surgical removal of larynx.
Electrolarynx is
An external device used to produce voice by emitting vibrations.
