Chapter 35- Sensory Perception Nursing School Test Banks

 

1.

A patient is refusing to take his prescribed medication. The patient states that the government is out to get him and is poisoning all of his medication. The nurse understands that the patient is experiencing

A)

an illusion.

B)

a delusion.

C)

an hallucination.

D)

confusion.

Ans:

B

Feedback:

Hallucinations, sensory impressions that are based on internal stimulations, have no basis in reality. Hearing voices when no one is there is a typical auditory hallucination. Delusions, beliefs not based in reality, reflect an unconscious need or fear. Illusions are misinterpretations of actual stimuli.

2.

The nurse is preparing a care plan for a patient with a nursing diagnosis of Disturbed Sensory Perception. Which of the following would be appropriate goals for this diagnosis? Select all that apply.

A)

The patient will demonstrate an understanding of contributing factors to disturbed sensory perceptions by reducing or eliminating them during the hospital stay.

B)

The patient will not fall during the hospital stay.

C)

The patient will develop an effective communication mechanism during the hospital stay.

D)

The nurse will use a communication board when speaking with the patient.

E)

The nurse will assist the patient with ADLs as needed during the hospital stay.

Ans:

A, B, C

Feedback:

Goals are patient-directed statements, not nurse directed. Examples of appropriate patient goals for Disturbed Sensory Perception may include the following: the patient will remain safe, the patient will demonstrate an understanding of contributing factors to disturbed sensory perceptions by reducing or eliminating them, the patient will maintain the functioning of existing senses, or the patient will develop an effective communication mechanism.

3.

The nurse understands that when a patient is talking about the voices in their head, the patient is experiencing

A)

a delusion.

B)

an hallucination.

C)

an illusion.

D)

confusion.

Ans:

B

Feedback:

Hallucinations, sensory impressions that are based on internal stimulations, have no basis in reality. Hearing voices when no one is there is a typical auditory hallucination. Delusions are fixed beliefs, not based in reality. Illusions are misperceptions of actual stimuli.

4.

The nurse is caring for a patient at risk for sensory overload. What interventions should the nurse implement? Select all that apply.

A)

Remove clutter from the patients room

B)

Implement measures to reduce the patients pain

C)

Assist with all ADLs

D)

Limit interruptions to the patients rest/sleep times

E)

Limit extraneous noise

Ans:

A, B, D, E

Feedback:

If the patient is experiencing sensory overload, interventions should focus on reducing stimulation involving information, the environment, and internal factors. Limiting extraneous noise, bright lights, room clutter, interruptions, pain, and stress reduces stimulation. Patients with sensory overload may neglect their ADLs to the point that they need assistance. Such assistance can be problematic because it can add to sensory overload. With this in mind, assist the patient only with the immediately essential ADLs (moving, eating, toileting, and resting). Additional tasks may be added as the patient is able to cope.

5.

The nurse is caring for a patient at risk for sensory deprivation. What interventions should the nurse implement to decrease the patients risk? Select all that apply.

A)

Encouraging the patients family to bring in personal objects.

B)

Keeping the television on at all times

C)

Placing a clock and calendar in the patients room

D)

Brushing the patients hair

E)

Speaking slowly and clearly to the patient

Ans:

A, C, D, E

Feedback:

Measures to provide stimulation include playing the television or the radio occasionally, playing music for brief periods, encouraging use of a clock and calendar, encouraging the patient to dress for the days activities, putting up colorful pictures, encouraging visitors, encouraging family to bring in personal items such as photographs, opening the drapes, and turning on lights. Place the bed or chair so the patient can see or hear activities in the area and when someone enters the room. Frequent interaction with the patient also may help. Discussing scheduling of care and placement of equipment, encouraging self-care activities, providing tactile stimulation through backrubs, combing and brushing the patients hair (or encouraging the patient to do so), reading to the patient, speaking slowly and clearly, and identifying yourself verbally and with a name tag are meaningful interactions.

6.

Which of the following patients is at greatest risk of sensory overload?

A)

A 17-year-old on bedrest after a surgical procedure

B)

A 55-year-old, newly diagnosed with diabetes, in a private room in a hospital

C)

An 88-year-old on a ventilator in an intensive care unit

D)

An 8-year-old in isolation in a private room in a hospital

Ans:

C

Feedback:

Private rooms, mobility restraints (such as traction or bedrest), isolation, and few visitors are all risk factors for sensory deprivation. Intensive care units, mechanical ventilators, lengthy verbal explanations prior to procedures and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload.

7.

Which patient is at greatest risk of developing sensory deprivation?

A)

An 84-year-old with progressive hearing loss living in an assisted living facility

B)

A 50-year-old newly diagnosed with breast cancer and having first chemotherapy treatment today

C)

A 32-year-old with a fractured pelvis, on bedrest in a private room

D)

An 18-year-old with a traumatic head injury who is in an intensive care unit

Ans:

C

Feedback:

Private rooms, mobility restraints (such as traction or bedrest), isolation, and few visitors are all risk factors for sensory deprivation. Intensive care units, lengthy verbal explanations prior to procedures, and decreased cognitive ability (e.g., head injury) are all risk factors for sensory overload.

8.

A nurse has just finished a presentation to a group of nursing assistants on ways to assist patients with sensory perception issues, such as low vision or hearing. What statement by a nursing assistant suggests a need for further education?

A)

I will stand directly in front of the patient and speak slowly.

B)

I will move the furniture around depending on what activities are planned for the day.

C)

I will use bright contrasting colors when making signs.

D)

I will keep fresh flowers in the television room.

Ans:

B

Feedback:

Examples of sensory aids include using large print materials, bright contrasting colors in the environment, uncluttered environment with no furniture rearranging, speaking slowly and distinctly while standing directly in front of the patient, and keeping fresh flowers in the room.

9.

A patient has received morphine for complaints of pain at a recent surgical incision site. After receiving the medication, the patient starts picking at the bedsheets and saying, Get the bugs off my bed, I can feel them crawling on me! Which nursing diagnosis is appropriate for this patient?

A)

Disturbed Sensory Perception: Kinesthetic related to side effects of medication as evidenced by patient statement of Get the bugs off my bed, I can feel them crawling on me.

B)

Disturbed Sensory Perception: Tactile as evidenced by patient statement of Get the bugs off my bed, I can feel them crawling on me.

C)

Disturbed Sensory Perception related to patient statement of Get the bugs off my bed, I can feel them crawling on me

D)

Disturbed Sensory Perception: Tactile related to side effects of medication as evidenced by patient statement of Get the bugs off my bed, I can feel them crawling on me.

Ans:

D

Feedback:

Disturbed Sensory Perception: Tactile related to side effects of medication as evidenced by patient statement of Get the bugs off my bed, I can feel them crawling on me is the correctly written nursing diagnosis. Since the nursing diagnosis is not a risk for diagnosis, it must have a related to and as evidenced by statement.

10.

The student nurse is preparing a presentation on sensory perception. What symptoms of sensory deprivation should the student include? Select all that apply.

A)

Depression

B)

Increased appetite

C)

Sleeplessness

D)

Decreased interest in activities

E)

Increased interest in interactions with others

Ans:

A, C, D

Feedback:

Depression may result from sensory deficits or sensory deprivation. Helplessness and loss of self-esteem lead to depression and withdrawal. The patient who is placed on isolation precautions may show signs of poor appetite, sleeplessness, and loss of interest in activities or interaction with others as he or she becomes depressed, leading to further sensory deprivation.

11.

A student nurse is preparing a presentation on sensoryperception . What symptoms of sensory overload should the student include? Select all that apply.

A)

Disorientation

B)

Sleeplessness

C)

Confusion

D)

Increased work performance

E)

Fatigue

Ans:

A, B, C, E

Feedback:

Disturbances in remembering, reasoning, and problem solving can occur with sensory overload. Decision making may be irrational or dysfunctional. Other common behaviors indicative of cognitive dysfunction include disorientation; verbalizing disconnected thoughts; complaining of too much going on, sleeplessness, and fatigue; inability to think; and poor work performance.

12.

The nurse is caring for a patient who has been placed in respiratory isolation. The nurse understands that the patient is at risk for:

A)

Sensory overload

B)

Sensory deprivation

C)

Sensoristasis

D)

Sensory perception

Ans:

B

Feedback:

Deprived environments can have negative effects on a persons sensoristasis. A person who is immobilized or isolated for any reason is deprived of the usual amount of stimulation and may show manifestations of sensory deprivation.

13.

A patient has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the patient. When the physician leaves the room, the patient asks the nurse, What did he just say? The nurse understands that the patient is experiencing ____________.

A)

sensory overload

B)

sensory deprivation

C)

sensoristasis

D)

sensory perception

Ans:

A

Feedback:

Sensory overload occurs when a person is unable to process or manage the intensity or quantity of incoming sensory stimuli. Imparting information to a patient may lead to sensory overload. Some examples include teaching a patient about a procedure, informing a patient about a diagnosis, making requests of a patient, or helping the patient solve a problem.

14.

A patient with hearing loss gets very frustrated trying to carry on conversations with friends. Which type of stressor is the patient experiencing?

A)

Physical

B)

Psychological

C)

Sensory deficits

D)

Sociocultural

Ans:

C

Feedback:

Sensory deficits in vision and hearing interfere with ones ability to interact with other people and with the environment.

15.

A sensory deficit that may arise from the patients eyes being bandaged after eye surgery can result in

A)

Depression

B)

Psychic blindness

C)

Compensation

D)

Total disorientation

Ans:

D

Feedback:

A sudden loss of sensory perception through a sensory deficit can cause total disorientation because compensation does not occur immediately.

16.

A hospitalized patient who refuses to eat because she fears that the kitchen personnel are poisoning her food is experiencing

A)

Hallucinations

B)

Anorexia

C)

Agoraphobia

D)

Delusions

Ans:

D

Feedback:

Delusions, beliefs not based in reality, reflect an unconscious need or fear.

17.

When admitting a wheelchair-bound paraplegic patient to the hospital, the nurse assesses the patient for injuries that may occur as a result of sensory

A)

Alteration

B)

Overload

C)

Deprivation

D)

Progression

Ans:

A

Feedback:

Altered sensory reception occurs in such conditions as spinal cord injury, brain damage, changes in receptor organs, sleep deprivation, and chronic illness.

18.

A patient in the intensive care unit will experience less sensory overload

A)

If a clock displays date, time, AM/PM

B)

If the nurse silences the alarms

C)

If the nurse provides touch every hour

D)

If the family visits at all times

Ans:

A

Feedback:

Disorientation can occur when expected day/night differences in levels of general activity are lost. To reduce such disorientation, provide a clock displaying a clear distinction of AM/PM time, day, and date. Silencing the alarms could compromise the patients care.

19.

The nurse determines that when a female patient who underwent a mammogram earlier in the day is asked to have a breast ultrasound and is informed that she demonstrates signs of breast malignancy, the patient is at risk for experiencing sensory

A)

Adaptation

B)

Deprivation

C)

Stimulation

D)

Overload

Ans:

D

Feedback:

When the reticular activating system (RAS) is overwhelmed with input, a person may experience sensory overload and feel confused, anxious, and unable to take constructive action.

20.

When the patient who has been hospitalized for 8 days for skin grafting tells the nurse that he is bored, depressed, and restless, the nurse determines that the patient is experiencing sensory

A)

Deprivation

B)

Adaptation

C)

Perception

D)

Overload

Ans:

A

Feedback:

When the RAS fails to recognize a stimulus because it is below the threshold level or lacks relevant meaning to the person, sensory deprivation may occur, and the person experiences boredom, depression, restlessness, and vivid sensual imagery, including hallucinations.

21.

The nurse taking care of a 3-year-old who is on a 10-regimen dose of gentamicin should instruct the mother to

A)

Have the vision tested in 6 weeks

B)

Have the gentamicin levels tested in 6 weeks

C)

Have the peripheral nervous system tested in 6 weeks

D)

Have the hearing tested in 6 weeks

Ans:

D

Feedback:

Some antibiotics, including streptomycin and gentamicin, can damage the auditory nerve, impairing hearing.

22.

An intensive care unit nurse does not notice the noise within her environment. However, the patients family member states, How can you stand it in here? The lights, sounds, and activity would drive me crazy and I couldnt take it. The nurse has adapted to her

A)

Intensive care unit work

B)

Intensive care unit environment

C)

Threatening stimuli

D)

Nursing career

Ans:

B

Feedback:

Sensory stimulation in the environment effects sensory perception. After routine exposure to stimulation, the body adapts.

23.

To meet the learning needs of the older adult, the nurse incorporates which of the following considerations in planning to teach a 73-year-old diabetic patient about insulin administration?

A)

Requesting hearing aids to help the patient receive information

B)

Using numerous handouts and detailed teaching plan

C)

Allowing more time for the processing of the information

D)

Demonstrating a wide variety of syringes and techniques

Ans:

C

Feedback:

As a person approaches 60 to 70 years of age, marked decrements in sensory/perceptual behaviors begin. This reduction in efficiency means that older people cannot process sensory input as rapidly as they did when they were young.

24.

When a new mother asks the nurse whether her newborn infant can see her, the best response by the nurse is to tell the mother that her infant

A)

Cannot see for 2 weeks of age

B)

Can differentiate objects only

C)

Can differentiate colors only

D)

Can see light and dark patterns

Ans:

D

Feedback:

Newborns see only gross patterns of light and dark or bright colors. As they grow, vision becomes more discriminating.

25.

In the process of adaptation, the nursing student prepares for her day in her mind. She tells herself that she can overcome her fears and anxiety to give good care. This is an example of

A)

Emotional stability

B)

Sensory deprivation

C)

Lead time

D)

Afterburn

Ans:

C

Feedback:

Lead time is the time each person needs to prepare for an event emotionally and physically.

26.

A nursing student is attending her first day of clinical. She is very alert to the workings of the clinical division and the care of her patient. This is an example of

A)

Sensoristasis

B)

Stimulation

C)

Arousal

D)

Adaptation

Ans:

A

Feedback:

Sensoristasis is a state of optimum arousalnot too much and not too little.

27.

When a person selects, organizes, and interprets sensory stimuli, the process is termed

A)

Adaptation

B)

Perception

C)

Stimulation

D)

Preoccupation

Ans:

B

Feedback:

Sensory perception is a conscious process of selecting, organizing, and interpreting sensory stimuli that requires intact and functioning sense organs, nervous pathways, and the brain.

28.

During a patient assessment, the nurse has the patient close his eyes. She then places her finger on his right thigh. She asks the patient where he is being touched and he answers my right thigh. This is an example of which sense?

A)

Auditory

B)

Visual

C)

Kinesthetic

D)

Olfactory

Ans:

C

Feedback:

The kinesthetic sense influences the awareness of placement and action of body parts.

29.

A patient who has awakened from a coma after a car accident states he knew about a news story reported during the time he was in the coma. The is an example of the

A)

Reticular-activating systems stimulation

B)

Sleep-latency phase of sleep-wake cycle

C)

Circadian rhythm for 24 hours

D)

Sensory perception in a conscious process

Ans:

A

Feedback:

Destruction of the reticular-activating system (RAS) produces a coma and an electroencephalograph pattern consistent with sleep. When the nervous system is oriented to a stimulus and receptive toward it, the neurons of the RAS arouse the brain, facilitating information reception (Widmaier, Raff, & Strang, 2008). The RAS is highly selective.

30.

A patient in the intensive care unit becomes very cognizant of the nurses touch. This is a function of which system?

A)

General adaptation syndrome

B)

Local adaptation syndrome

C)

Reticular activating system

D)

Peripheral nervous system

Ans:

C

Feedback:

The reticular activating system (RAS) is responsible for bringing together information from the cerebellum and other parts of the brain with that obtained from the sense organs. Awareness of the world depends on the RAS, which is located between the nerve centers of the medulla oblongata in the brain stem. Sensory, visceral, kinesthetic, and cognitive input stimulate the RAS.

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