Unit 7: Ch. 31 Cognitive and Sensory Alterations Flashcards
. A visually impaired diabetic patient states that he has lost the call light. What is the next action the nurse should take?
a. Clip the call light closer to the patient.
b. Tell the patient that the call light is clipped to the bed.
c. Describe the call light location; then, take the patient’s hand and guide it to that location.
d. Instruct the patient to verbally call for a staff member because “someone is always nearby.”
Answer: c
Always leave the call light within easy reach of the patient. Use of the patient’s senses of touch and hearing enables the patient to locate the call light easier. Simply telling the patient that the call light is clipped to the bed is not adequate because the patient will not know where on the bed to look. Verbally calling for the nurse is not acceptable because the nurse and other staff members might be out of hearing range.
When caring for a hearing-impaired patient, use of which action by the nurse would facilitate communication?
a. Speaking clearly with distinct words
b. Talking slowly to facilitate understanding
c. Sitting behind the patient to decrease distractions
d. Standing near the patient’s affected ear to balance sound
Answer: a
Speaking clearly without shouting facilitates communication with the hearing-impaired patient by giving each word separate emphasis. Talking distinctly, but not too slowly, and allowing the patient to see facial expressions and read lips, with the use of hearing aids if prescribed, are good communication techniques. Speaking into the ear with the better hearing is recommended.
The nurse is caring for a patient with decreased sensation in the lower extremities. Which precaution does the nurse advise the patient to take?
a. Use heat to warm hands during cold weather.
b. Go barefoot at home to prevent blisters from shoes.
c. Soak feet in cold water daily to decrease swelling.
d. Test the bath water temperature to prevent burning injuries
Answer: d
Because the patient may not be able to feel the temperature of the water, using a thermometer will prevent burns. The use of heat and cold is contraindicated in patients with tactile deficits because they would not be able to feel whether the therapy was too hot or cold. The patient should wear good-fitting shoes around the house to prevent foot injury.
Which statement by the patient with vertigo lets the nurse know that the patient has understood the home-going instructions?
a. “I will buy a visual signal for my smoke detectors.”
b. “I will have grab bars installed in my bathtub.”
c. “I will change positions quickly to avoid vertigo.”
d. “I will get a home phone with amplified sound.”
Answer: b
Grab bars provide stability for the patient with vertigo. Patients with vertigo should change positions slowly to avoid worsening of the spinning sensation. Visual signals and amplified sound are used in the home of the patient with hearing deficits.
Which nursing action is appropriate for a patient with sensory overload?
a. Dimming the lights
b. Performing care a little at a time
c. Leaving the patient’s door open
d. Rushing to get care done quickly
Answer: a
Dimming the lights decreases sensory stimuli which alleviates sensory overload. Constant disruption adds to the overload, as does leaving the door open and rushing while in the room. A calm, quiet atmosphere diminishes the overload.
Which recommendation in the home-going instructions is appropriate for a patient with damage to the chemoreceptors of the upper nasal passages?
a. Arranging for lighted signals on doorbells and telephones
b. Obtaining a thermometer for testing bath water temperature
c. Installing amplification devices on televisions, doorbells, and telephones
d. Scheduling yearly safety checks of gas hot water heaters and furnaces.
Answer: d
Patients with damage to the chemoreceptors of the nasal passages may not be able to smell noxious fumes from household appliances. Lighted signals and amplification are interventions for a person with auditory deficits. Testing the bath water temperature is important for patients with tactile deficits.
When caring for an elderly patient who presents with acute confusion of sudden onset, which test would the nurse expect to be ordered?
a. Urine culture and sensitivity testing
b. Mini-Mental State Examination (MMSE)
c. Swallow evaluation
d. Magnetic resonance imaging (MRI) with contrast
Answer: a
A major cause of acute confusion in the elderly is infections, including urinary tract infections and pneumonia. Urine culture and sensitivity testing will detect bacteria in the urine and determine proper antibiotic treatment. A MMSE is a valuable tool to assess the progression of dementia. Swallow evaluation is done in patients who are suspected of having a weak or absent gag reflex. MRI with contrast might be done in a patient with confusion after infection has been ruled out.
Which nursing diagnosis is most appropriate for a patient with expressive aphasia?
a. Impaired Verbal Communication
b. Acute Confusion
c. Self-Care Deficit
d. Impaired Mobility
Answer: a
Expressive aphasia occurs when people are not able to express themselves with words. They might be able to understand what is being said but not able to respond appropriately. Therefore, Impaired Verbal Communication is most appropriate. The nursing diagnosis of Acute Confusion is appropriate for patients who are not oriented to person, place, time, or situation. The diagnosis of Self-Care Deficit would apply to a patient who cannot independently take care of activities of daily living (ADLs). Patients with limitations of movement may have a nursing diagnosis of Impaired Mobility.
Which nursing interventions would be necessary in caring for a patient with cognitive alterations who is hospitalized? (Select all that apply.)
a. Apply wrist restraints for combativeness.
b. Place a clock in the room for orientation.
c. Keep floor free of clutter for safety.
d. Identify staff with each interaction.
e. Play loud music for distraction.
Answers: b, c, d
Reality orientation is important for patients with cognitive alterations. Keeping the floor free of clutter prevents falls. All staff members should wear a readily visible name tag and state their name and what they are going to do. Soft music and dim lights will create a less distracting environment for the patient. Restraints may cause increased confusion and agitation and are used in special circumstances only.
Which goal statement is appropriate for a patient with the nursing diagnosis of Acute Confusion?
a. Patient will remember nurse’s name.
b. Nurse will remind patient of his or her name each shift.
c. Patient will state name and date with each nursing encounter.
d. Nurse will remind patient of name and date with each nursing encounter.
Answer: c
Goals are always patient-centered and measurable and have a specified time frame. A patient goal would not include a nursing behavior. A confused patient would not be expected to remember different nurses’ names but would be assessed for person, place, and time orientation with each encounter.
A change in the environment sufficient to evoke a response.
Stimulus
Age-related hearing loss.
Presbycusis
Crossing over of sensory pathways
Decussate
Speech or language impairment
Aphasia
Sense of smell
Olfaction
Detectable by touch
Tactile
Knowing influenced by awareness and judgement
Cognition
Complete loss of the sense of smell
Anosmia
Sense of taste
Gustation
Age-related farsightedness
Presbyopia
What problems may a patient experience if the Frontal lobe is damaged?
The frontal lobes of the cerebrum are the areas of the brain responsible for voluntary motor function, concentration, communication, decision-making, and personality.
A patient with a problem in this area will have difficulty speaking, focusing, and completing ADLs, and will possibly experience mood swings.
