Sensory Perception Flashcards
Which client is at greatest risk for experiencing sensory overload? 1. A 40-year-old client in isolation with no family
2. A 28-year-old quadriplegic client in a private room
3. A 16-year-old listening to loud music 4. An 80-year-old client admitted for emergency surgery
- Answer: 4. Rationale: 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. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Evaluation. Learning Outcome: 38-3.
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?
1. Chronic Confusion
2. Impaired Memory
3. Acute Confusion
4. Disturbed Thought Processes
- Answer: 3. Rationale: 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. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Diagnosis. Learning Outcome: 38-6.
The nursing diagnosis Risk for Impaired Skin Integrity related to sensory-perception disturbance would best fit a client who:
1. Cut a foot by stepping on broken glass.
2. Uses a wheelchair due to paraplegia.
3. Wears glasses because of poor vision.
4. Is legally blind and smokes in bed.
- Answer: 2. Rationale: 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. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Diagnosis. Learning Outcome: 38-6.
Which statement indicates the client needs a sensory aid in the home?
1. “I tripped over that throw rug again.” 2. “I can’t hear the doorbell.”
3. “My eyesight is good if I wear my glasses.”
4. “I can hear the TV if I turn it up high.”
- Answer: 2. Rationale: 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. Cognitive Level: Analyzing. Client Need: Safe, Effective Care Environment. Nursing Process: Evaluation. Learning Outcome: 38-7.
A hospitalized client is disoriented and believes she is in a train station. Which response from the nurse is the most appropriate?
1. “You wouldn’t be getting a bath at the train station.”
2. “Let’s finish your bath before the train arrives.”
3. “Don’t you know where you are?” 4. “It may seem like a train station sometimes, but this is Valley Hospital.”
- Answer: 4. Rationale: Option 4 is the only response that helps orient the client and treats the client with respect. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 38-7.
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.
1. Identify yourself by name.
2. Decrease background noise before speaking.
3. Stay in the client’s field of vision.
4. Explain the sounds in the environment.
5. Keep your voice at the same level throughout the conversation.
- Answer: 1, 3, and 4. Rationale: Options 2 and 5 relate to interventions for a client with a hearing impairment. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Implementation. Learning Outcome: 38-7.
A client is exhibiting signs and symptoms of acute confusion/ delirium. Which strategy should the nurse implement to promote a therapeutic environment?
1. Keep lights in the room dimmed during the day to decrease stimulation.
2. Keep the environmental noise level high to increase stimulation.
3. Keep the room organized and clean. 4. Use restraints for client safety.
- Answer: 3. Rationale: 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). Cognitive Level: Applying. Client Need: Safe, Effective Care Environment. Nursing Process: Implementation. Learning Outcome: 38-8.
A client is at risk for sensory deprivation. Which of the following clinical signs would the nurse observe? Select all that apply.
1. Sleeplessness
2. Decreased attention span
3. Irritability
4. Excessive sleeping
5. Crying, depression
- Answer: 2, 4, and 5. Rationale: Options 1 and 3 are clinical signs of sensory overload. Cognitive Level: Remembering. Client Need: Psychosocial Integrity. Nursing Process: Assessment. Learning Outcome: 38-3.
The nurse is assessing for sensory function. Match the assessment tool to the specific sense it will be testing. Identifying taste
1. Visual Stereognosis Snellen chart Identifying aromas Tuning fork
2. Hearing
3. Tactile
4. Olfactory
5. Gustatory
- Answer: Identifying taste: 5; Stereognosis: 3; Snellen chart: 1; Identifying aromas: 4; Tuning fork: 2. Cognitive Level: Remembering. Client Need: Health Promotion and Maintenance. Nursing Process: Assessment. Learning Outcome: 38-4.
An 85-year-old client has impaired hearing. When creating the care plan, which intervention should have the highest priority?
1. Obtaining an amplified telephone
2. Teaching the importance of changing his position
3. Providing reading material with large print
4. Checking expiration dates on food packages
- Answer: 1. Rationale: 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. Cognitive Level: Applying. Client Need: Psychosocial Integrity. Nursing Process: Planning. Learning Outcome: 38-7.
