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fundamentals of nursing > final exam: chapter 45 (sensory functioning) > Flashcards

final exam: chapter 45 (sensory functioning) Flashcards

1
Q

what are the four factors that contribute to sensory alteration?
a. deficits
b. deprivation
c. overload
d. poverty
e. development
f. process

A

a-d

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2
Q

this kind of sensory alteration includes environment w/decreased stimuli, impaired ability to receive environmental stimuli (hearing, vision), and inability to process environmental stimuli.
a. deficit
b. deprivation
c. overload
d. poverty

A

b

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3
Q

what are the three disturbances that result from sensory deprivation?

A

perceptual (results from inaccurate perceptions of light, sound, etc.), cognitive (attention span and concentration decreased), and emotional

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4
Q

a pt is experiencing too much sensory stimuli, feels out of control, and exhibits manifestations observed in sensory deprivation. the nurse plans on reducing these stressful stimuli. what is the pt undergoing?
a. sensory overload
b. sensory output
c. sensory deficit

A

a

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5
Q

a 78 yo woman has impaired sight, hearing, altered taste, tactile perception, and impaired kinesthetic sense (awareness of position and movement of body parts). she has which kind of sensory alteration?

A

deficit

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6
Q

technology has created this kind of sensory alteration

A

poverty

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7
Q

what are the 5 factors that affect sensory stimulation?

A

culture | developmental considerations | meds | personality and lifestyle | stress and illness

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8
Q

sensory changes in the older adult affect (1) __, (2) __, (3) __ and __, and (4) __

A

vision; hearing; smell; taste; alteration in peripheral sensation

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9
Q

presbyopia, cataracts, macular degeneration, and glaucoma are all changes in __ for the older adult

A

vision

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10
Q

hearing loss, tinnitus, and meniere’s disease are changes in __ for the older adult

A

hearing

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11
Q

name the 7 conscious states: __ (hint: cddlmns)

A

confusion | delirium | dementia | locked-in syndrome | minimally conscious state | normal consciousness | somnolence

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12
Q

match the conscious states with their appropriate definition:
a. confusion
b. delirium
c. dementia
d. locked-in syndrome
e. minimally conscious state
f. normal consciousness
g. somnolence
1. disorientation, restlessness, confusion, hallucinations, agitation, alternating with other conscious states
2. difficulties with spatial orientation, memory, language; changes in personality
3. reduced awareness, easily distracted, easily startled by sensory stimuli, alternates between drowsiness and excitability; resembles minor form of delirium state
4. aware of self and external environment, well oriented, responsive
5. Extreme drowsiness, but will respond normally to stimuli
6. part consciousness; sleep–wake cycles present; some motor function, including automatic movements; inconsistently follows commands
7. full consciousness; sleep–wake cycles present; quadriplegic, auditory and visual function preserved; emotion preserved

A

a. 3
b. 1
c. 2
d. 7
e. 6
f. 4
g. 5

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13
Q

how can we prevent sensory alteration? (hint: bceeopu)

A

be aware of need for sensory aids & prostheses | control pt discomfort | encourage physical activity & exercise | enlist aid of family members to participate in/encourage activities | offer care providing rest & comfort | provide stimulation for as many senses as possible | use social activities to stimulate senses & mind

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14
Q

true or false. teach pt self-care behaviors to maintain vision & prevent blindness

A

true

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15
Q

you should __ your presence in the pt’s room (if they are visually impaired)

A

acknowledge

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16
Q

visually impaired pts: speak in a __ tone of voice

A

NORMAL

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17
Q

visually impaired pts: __ the reasoning for touching pt

A

explain

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18
Q

visually impaired pts: keep __ w/in reach

A

call light

19
Q

visually impaired pts: __ the pt to __ in the environment as well as __ arrangement and __

A

orient; sounds; room; furnishings

20
Q

visually impaired pts: assist with ambulation by walking __ of the pt

A

slightly ahead

21
Q

visually impaired pts: stay in pt’s __

A

field of vision

22
Q

visually impaired pts: indicate conversation has ended when __

A

leaving the room

23
Q

hearing-impaired pts: orient them to your __ before speaking

A

prescence

24
Q

hearing-impaired pts: decrease __ before speaking

A

background noises

25
Q

hearing-impaired pts: check the pt’s __ aids

A

hearing

26
Q

hearing-impaired pts: position yourself so __ is on your face

A

light

27
Q

hearing-impaired pts: talk __ to the pt and face them

A

directly

28
Q

hearing-impaired pts: write any __ you cannot convey

A

ideas

29
Q

confused pt: use frequent __to__ to communicate

A

face;face

30
Q

confused pts: speak __, simply, and __ to pt

A

calmly; directly

31
Q

confused pts: orient & reorient them to __ and to __, __, and __

A

environment; time; place; person

32
Q

confused pts: use __, __, __ and __ to help orient the pt

A

clocks; calendar; newspapers; tv

33
Q

confused pts: offer __ explanation for care

A

simple

34
Q

confused pts: use objects from __ or __

A

home; past

35
Q

confused pts: focus on client’s __

A

strengths

36
Q

name the 4 unconscious states (hint: acsv)

A

asleep | coma | stupor | vegetative state

37
Q

__ : can be aroused by normal stimuli (light, touch, sound, etc.)

A

asleep

38
Q

__ (asleep/stupor/coma) CANNOT BE AROUSED & DOES NOT respond to stimuli

A

coma

39
Q

__ (asleep/stupor/coma/veggie state) CAN BE AROUSED by extreme and/or repeated stimuli

A

stupor

40
Q

__ (asleep/stupor/coma/veggie state) CANNOT BE AROUSED. sleep–wake cycles, postures or withdraws to noxious stimuli, occasional non-purposeful movement, random smiling or grimacing

A

veggie state

41
Q

the highest score on the glasgow coma scale is __

A

15

42
Q

a score of <8 indicated __ on the glasgow coma scale

A

comatose client

43
Q

a score of 3 on the glasgow coma scale indicates __

A

totally unresponsive

fundamentals of nursing (17 decks)

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