Sensory Perception (38) Flashcards
Which client is at greatest risk for experiencing sensory overload?
- A 40-year-old client in isolation with no family
- A 28-year-old quadriplegic client in a private room
- A 16-year-old listening to loud music
- An 80-year-old client admitted for emergency surgery
4. An 80-year-old client admitted for emergency surgery
A sudden, unexpected admission for surgery may involve many experiences (e.g., lab work, x-rays, signing of forms) while the client is in pain or some form of discomfort. The time for orientation will thus be lessened.
After surgery, the client may be in pain and possibly in a critical care setting.
Options 1 and 2 reflect a greater risk for sensory deprivation, and option 3 is a normal activity for a teenager.
An alert 80-year-old client is transferred to a long-term care facility. On the second night, he becomes restless and agitated. What is the most appropriate nursing diagnosis?
- Chronic Confusion
- Impaired Memory
- Acute Confusion
- Disturbed Thought Processes
3. Acute Confusion
The transfer to a different setting can change the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli.
The onset of restlessness and agitation is a characteristic of acute confusion.
Options 1 and 2: There is no evidence of longstanding or progressive deterioration of intellect and personality.
Option 4: Disturbed Thought Processes is applied when cognitive abilities (e.g., dementia) interfere with the ability to accurately interpret stimuli.
The nursing diagnosis Risk for Impaired Skin Integrity related to sensory-perception disturbance would best fit a client who:
- Cut a foot by stepping on broken glass.
- Uses a wheelchair due to paraplegia.
- Wears glasses because of poor vision.
- Is legally blind and smokes in bed.
2. Uses a wheelchair due to paraplegia.
Because of the paraplegia (paralysis of lower body), the client is unable to feel discomfort. The client will be taught to lift self using chair arms every 10 minutes if possible.
Option 1 is an actual problem versus a potential problem.
In option 3, the client wears glasses that help correct the poor vision.
Option 4 is more of a Risk for Injury diagnosis.
Which statement indicates the client needs a sensory aid in the home?
- “I tripped over that throw rug again.”
- “I can’t hear the doorbell.”
- “My eyesight is good if I wear my glasses.”
- “I can hear the TV if I turn it up high.”
2. “I can’t hear the doorbell.”
This client could use an assistive device that flashes a light when the doorbell rings.
Option 1 relates to safety of the environment rather than sensory alteration.
Options 3 and 4 reflect how the client adapts to the sensory alteration.
A hospitalized client is disoriented and believes she is in a train station. Which response from the nurse is the most appropriate?
- “You wouldn’t be getting a bath at the train station.”
- “Let’s finish your bath before the train arrives.”
- “Don’t you know where you are?”
- “It may seem like a train station sometimes, but this is Valley Hospital.”
4. “It may seem like a train station sometimes, but this is Valley Hospital.”
Option 4 is the only response that helps orient the client and treats the client with respect.
A client with impaired vision is admitted to the hospital. Which interventions are most appropriate to meet the client’s needs? Select all that apply.
- Identify yourself by name.
- Decrease background noise before speaking.
- Stay in the client’s field of vision.
- Explain the sounds in the environment.
- Keep your voice at the same level throughout the
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conversation.
1. Identify yourself by name.
3. Stay in the client’s field of vision.
4. Explain the sounds in the environment.
Options 2 and 5 relate to interventions for a client with a hearing impairment.
A client is exhibiting signs and symptoms of acute confusion/ delirium. Which strategy should the nurse implement to promote a therapeutic environment?
- Keep lights in the room dimmed during the day to decrease stimulation.
- Keep the environmental noise level high to increase stimulation.
- Keep the room organized and clean.
- Use restraints for client safety.
3. Keep the room organized and clean.
A disorganized, cluttered environment increases confusion.
Option 1: Keeping the room well lit during waking hours promotes adequate sleep at night.
It is important to eliminate unnecessary noise (option 2).
Client does not meet the standard criteria for restraint application (option 4).
A client is at risk for sensory deprivation. Which of the following clinical signs would the nurse observe? Select all that apply.
- Sleeplessness
- Decreased attention span
- Irritability
- Excessive sleeping
- Crying, depression
2. Decreased attention span
4. Excessive sleeping
5. Crying, depression
Options 1 and 3 are clinical signs of sensory overload.
The nurse is assessing for sensory function. Match the assessment tool to the specific sense it will be testing.
Identifying taste 1. Visual
Stereognosis 2. Hearing
Snellen chart 3. Tactile
Identifying aromas 4. Olfactory
Tuning fork 5. Gustatory
Identifying taste: 5. Gustatory
Stereognosis: 3. Tactile
Snellen chart: 1. Visual
Identifying aromas: 4. Olfactory
Tuning fork: 2. Hearing
An 85-year-old client has impaired hearing. When creating the care plan, which intervention should have the highest priority?
- Obtaining an amplified telephone
- Teaching the importance of changing his position
- Providing reading material with large print
- Checking expiration dates on food packages
1. Obtaining an amplified telephone
The amplified telephone helps with hearing and provides a means for communicating with others.
Option 2 refers to a tactile impairment.
Option 3 relates to a visual impairment, and option 4 an olfactory impairment.
An 81-year-old client noted that the vision in his left eye was becoming progressively “weaker.” No pain was associated with his vision loss, but his eye appeared cloudy and his vision was blurred. He could not discriminate colors. Eventually it began to interfere with his bird carving, a hoppy he took up after retirement and thoroughly enjoyed.
Cataracts
Treatment = surgery
A 75-year-old retired female plumber had a history of type 2 diabetes mellitus. During a recent eye examination, she was told by the ophthalmologist that she had increased intraocular pressure (IOP). When telling the nurse her history, she explained that she noticed she was bumping into objects at home that were apparently in her way. She realized that she was experiencing visual changes that were insidious in their onset and that she was unaware until now that she even had them. In addition to an IOP of 30 mm Hg, the ophthalmologist noted optic cupping.
Open Angle Glaucoma
Medication initially, then possibly surgery
90% of primary glaucoma.
Most common risk factor is high intraocular pressure due to build-up of aqueous humor.
Symptoms:
- No symptoms in early stages.
- Peripheral vision loss as disease progresses (not noticeable until it is too late).
- Blindness in advanced stages.
- Reason why glaucoma is known as “the silent theif of sight.”
A client, 73 years of age, experienced severe vertigo accompanied by nausea and vomiting. The vertigo made her feel light-headed, off-balance, and unsteady. During such episodes she had a loud, low-pitch roaring tinnitus, and she noticed that she had lost her hearing in her left ear.
Meniere’s Snydrome
Low Na+ diet, diuretic
A 68-year-old female photographer who had processed her own film in a dark room for many years, began to experience periods of blurred vision, frontal headache, and eye pain. In addition to these symptoms, she was puzzled by the halos she saw around white lights on the streets when she drove home late at night. She attributed these sensations to stress and fatigue. However, when the pain in her right eye became excruciating and unbearable, she sought help.
Narrow Angle Glaucoma / Angle Closure Glaucoma
A 60-year-old male client noticed flashes of light and “floaters” for several weeks. He was examined by his ophthalmologist. He described his symptoms as like a “shade were being drawn over part of my visual field.” He did not complain of pain. However, he was very anxious about the meaning of his symptoms.
Retinal Detachment / Detached Retina
Lay on infected side
Clinical Manifestations:
- Shade or curtain coming across vision of one eye.
- Cobwebs
- Bright flashing lights.
- Sudden onset of great number of floaters.
- No pain
