Sensory Perception Chapter 29

Question 1

Sensory Systems

Answer 1

	 Vision
		 Hearing
		 Taste
		 Smell
		 Touch

Question 2

The Senses

Answer 2

	Provide information about 
	•	Internal environment
	•	External environment
		Enable people to experience the world
		Allow response to changes

		Help body maintain homeostasis

		Necessary for human growth and development

Question 3

Components of the Sensory Experience

Answer 3

Stimulus

Reception

Perception

Arousal

Response to Sensations

Question 4

Stimulus

Answer 4

Trigger that stimulates receptor
Meaning depends on reception and processing
(e.g., loud noise, bright light, sour fruit)

Question 5

Reception

Answer 5

Process of receiving stimuli from nerve endings
Occurs through receptors
(e.g., thermoreceptors, proprioceptors, photoreceptors)

Question 6

Perception

Answer 6

Ability to interpret sensory impulses
Ability to give meaning to impulses
Affected by
Location of receptor
Number of receptors activated
Frequency of action potentials
Changes in above

Question 7

Arousal

Answer 7

Composed of consciousness and alertness
Mediated by RAS
Affected by
Environment
Medications

Question 8

Response to Sensations

Answer 8

Factors affecting response
Intensity of stimulus
Contrasting stimuli
Adaptation to stimuli
Previous experience

	Requires people to be 
•	Alert
•	Receptive to stimulation

Question 9

Question

The client who has had a stroke states to the nurse, “You know I can’t even tell where my left leg IS.”  This reflects lack of response to stimuli by the

a. mechanoreceptors
b. proprioceptors
c. thermoreceptors
d. chemoreceptors

Answer 9

b. proprioceptors

Question 10

Factors Affecting Sensory Function

Answer 10

	Age/stage of life
		Culture
		Illness
		Medications
		Stress
		Personality
		Lifestyle

Question 11

Sensory Alterations

Answer 11

	Sensory deprivation
		Sensory overload
		Impaired vision
		Impaired hearing
		Impaired taste
		Impaired smell
		Impaired tactile perception
		Impaired kinesthetic sense

Question 12

Nursing Interventions for Common Sensory Alterations

Sensory Deprivation

Answer 12

Focus is prevention
Support senses (e.g., glasses, hearing aids)
Orientation
Calendar; view of environment

Provide stimuli
Regular contact; touch
Television/radio
Pet therapy
Smells

Question 13

Nursing Interventions for Common Sensory Alterations (Cont’d)

Sensory Overload


Answer 13

Minimize stimuli
Less light, noise
Less television/radio
Calm tone
Reduce noxious odors
		Provide rest
		Teach stress reduction

Question 14

Mr. Arbor complains to the nurse that he is feeling anxious. He states, “I’m just so tired of all these tests they are doing, and it’s so noisy here at night.” Mr. Arbor’s pulse is 110 bpm, and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following?

a. Turn on the television to provide distraction.
b. Ask the client if he would like to discuss his anxiety further.
c. Close the blinds, dim the lights, and ask the patient what other measures would help him rest.
d. Call the physician and obtain an order for an anti-anxiety

Answer 14

c. Close the blinds, dim the lights, and ask the patient what other measures would help him rest.


Question 15

Nursing Interventions for Common Sensory Alterations (Cont’d)

Impaired Vision

Answer 15

Attend to glasses
Sufficient light
Protect eyes in sunlight
Magnifying lens/
large-print books
		

	Evaluate
•	Ability to perform ADLs
•	Ability to remain safe in the environment
•	Need for assistance  seeing eye dog

Question 16

Nursing Interventions for Common Sensory Alterations (Cont’d)

Impaired Hearing

Answer 16

Care of a hearing aid
Closed-caption television
Regular inspection of ear canals
Techniques to improve communication
Promote safety
Assess for social isolation

Question 17

Nursing Interventions for Common Sensory Alterations (Cont’d)

Impaired Gustatory

Answer 17

Frequent oral care/assess for lesions
Check for proper denture fit
Season foods appropriately

Drink water between food bites to help distinguish food taste

Question 18

Nursing Interventions for Common Sensory Alterations (Cont’d)

Impaired Tactile (loss)

Answer 18

Inspect for wounds
Stimulate senses by brushing hair, back rub, touching when giving care
Frequent turn and reposition
Impaired Tactile (excess sensitivity)
Minimize irritating stimuli such as loose linens

Question 19

Nursing Interventions for the Confused Client

Answer 19

	Reorient frequently
	•	State your name; day, date, time
	•	Provide clocks, calendars
	•	Visual clues to time
	•	Use personal belongings
		Maintain safe environment		 (continued→)
		Communicate clearly, slowly
	•	Respond to feelings
	•	Use gestures
		Limit choices
		Promote feelings of security
		Use alternative therapies

Question 20

Nursing Interventions for the Unconscious Client

Answer 20

	Continue orientation to reality
		Safety measures
	•	Bed in low position
	•	Side rails up
	•	Bed/chair alarm
	•	Doors & windows closed
	•	No medications within patient reach
			Attend to body systems
	•	Eye care
	•	Range of motion
	•	Skin care/mouth care
	•	Urinary drainage
	•	Bowel management
	•	Nutrition

Question 21

For any patient with an altered level of consciousness, the Glasgow Coma Scale score will help the nurse in planning care.

a. true
b. false

Answer 21

true