Unit V

Question 1

reception

Answer 1

• receptor (nerve cell) is stimulated
• nerve impulse travels from receptor to spinal cord or directly to brain
• sensory experience

Question 2

perception/awareness

Answer 2

receiving region of the cerebral cortex interprets the quality and nature of sensory stimuli

Question 3

level of consciousness (LOC)

Answer 3

influences how well stimuli is received and interpreted

Question 4

reaction to sensory stimuli

Answer 4

• action taken by the person after the meaning has been given (perceived)
• usually only react to stimuli that are most meaningful
• continual reception of the same stimulant causes cessation of the response: it goes unnoticed

Question 5

sensory deficit

Answer 5

• impairment of sight, hearing, taste, touch (including pain and pressure), smell or sense of position
• may be torn with or develop
• successful compensation is often possible
• sudden loss makes adjustment harder

Question 6

sensory deprivation

Answer 6

• inadequate quality of quantity of sensory stimulation
• may be physiologic
• may be due inadequate amount or variety of stimuli
  ex. bed rest
• may be experience CNS changes such as impaired judgement, confusion, hallucinations

Question 7

sensory overload

Answer 7

• when stimuli in the environment are excessive or beyond the person’s ability to absorb or comprehend
• stressful
• high anxiety
• sleeping pattern
• confusion
• aggression
• sights, smells, sounds
• can lead to sensory perceptual alterations

Question 8

physiologic

Answer 8

• tumors
• vascular
• stroke
• rupture
• trauma to head
• metabolic
• DM
• vitamins deficiency
• degenerative diorders
• Alzheimer’s
• medication side effects
• chemotherapy/radiation

Question 9

vision

Answer 9

• visual acuity using Snellen chart
• distance at which patient holds materials to read
• burred vision, blind spots, double vision, halos around lights, floaters

Question 10

hearing

Answer 10

• acuity in normal conversation, whispering, watch, tuning fork
• speech and language development in kids
• presence of tinnitus
• ask significant other if patient is responding appropriately

Question 11

taste

Answer 11

• ability to taste
• decrease in appetite
• increased use of seasonings to make food taste good
• difficulty swallowing

Question 12

smell

Answer 12

• ability to distinguish odors

- ask about ability to smell food

Question 13

touch

Answer 13

• ability to distinguish between sharp and dull
• ability to feel light touch
• ability to differentiate between hot and cold
• ask about numbness, tingling or prickling sensations

Question 14

position (proprioception)

Answer 14

• assess ability to walk in a straight line
• assess ability to stand still with feet together
• ask about dizziness, motion sickness, nausea, change in steadiness and/or gait

Question 15

level of consciousness (LOC)

Answer 15

• time
• place
• person
• president
• year

Question 16

environment

Answer 16

• hazards at home

- hazards in hospital

Question 17

hazards at home

Answer 17

• stairs
• clutter
• furniture
• stimuli

Question 18

hazards in hospital

Answer 18

• furniture

- equipment

Question 19

stimuli

Answer 19

• pets
• radio/TV
• clock/calendar
• pictures
• tubes
• noise

Question 20

assessment

Answer 20

• speech
• listening (hearing)
• verbal/nonverbal
• posture
• readiness to communicate

Question 21

nursing diagnoses

Answer 21

• alteration in communication

- impaired verbal communication

Question 22

planning

Answer 22

• what is needed to be done to enhance the communication process
• what can the patient do
• what will the nurse do
• review resources

Question 23

implementation

Answer 23

• safety is top priority
• maintain stimulating environment
• health promotion
• acute care
• continuing care

Question 24

health promotion

Answer 24

better diet/choices

Question 25

evaluation

Answer 25

• patient/client care
• was goal met?
• patient/client expectations
• did nursing meet your expectations?

Question 26

gerontological nursing

Answer 26

• treatment of older people and all aspects of the aging process and its consequences
• health promotion
• education
• disease prevention

Question 27

geriatrics

Answer 27

• branch of health care dealing with physiology and psychology of aging
• diagnosis and treatment of diseases affecting older adults

Question 28

ageism

Answer 28

• prejudices, sterotypes and myths that are applied to older people based solely on their age
• old people are sick and disabled
• most old people are in nursing homes
• senility comes with old age
• intelligence decreased with age
• not interested in sex
• few satisfactions

Question 29

vital signs

Answer 29

• temperature
• pulse
• respiration
• cardiac

Question 30

temperature

Answer 30

• extremities cooler

- less perspiration

Question 31

pulse

Answer 31

• peripheral pulse easy to palpate

- pedal pulses diminished

Question 32

respirations

Answer 32

rate increases

Question 33

cardiac

Answer 33

• B/P rate 140-160/80-90

- related to decreased cardiac output

Question 34

hearing

Answer 34

• presbycussis

- decreased pitch discrimination

Question 35

presbycussis

Answer 35

progressive loss of hearing acuity

Question 36

vision

Answer 36

• presbyopia
• depth in perception difficulties
• delayed glare recovery time
• decreases light/dark adaptation, impaired night vision
• decreased color discrimination

Question 37

presbyopia

Answer 37

progressive loss of visual acuity

Question 38

taste

Answer 38

• decreased acuity of taste; decreased saliva flow
• diminished in most people over 60
• smoking may atrophy taste buds sooner

Question 39

smell

Answer 39

• diminished ability to smell
• diminished ability to discriminate smells
• affects taste as well
• declines in persons over 70

Question 40

neurological

Answer 40

• slower reflexes
• decreased ability to respond to multiple stimuli
• insomnia
• shorter sleeping periods

Question 41

reproductive

Answer 41

• female

- male

Question 42

female

Answer 42

• decreased estrogen
• vaginal dryness
• decreased secretions

Question 43

male

Answer 43

• decreased testosterone

- decreased sperm count

Question 44

teaching

Answer 44

• keep living areas well lighted, free of clutter, keep eyeglasses in good condition, avoid night driving
• proper working assistive devices (canes, rails in tub and bathroom, elevated seats) nonskid strips in bathtub
• avoid smoking in bed, lower thermostats on water heaters, avoid overloading electrical outlets, install and maintain smoke and carbon monoxide detectors
• drive only short distances and in the daylight, avoid driving in inclement weather (fog, heavy rain, snow), use side and rear view mirrors, look behind them toward their blind spot before switching lanes, keep window rolled down in order to hear sirens and horns
• proper handling and storage of medications and safe methods of scheduling and taking medications
• drug interactions, signs and symptoms of drug toxicity to report to their health care provider
• ways to meet expectations with the patient’s capabilities, how to incorporate earlier life skills and interests, provide calm, caring, and structured environment