Chapter 48: Sensory Alterations Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. During a community screening, the nurse informs a 50-year-old African American client about the frequency of eye examinations. It is recommended that individuals in this age group have eye examinations:

a.

Every 3 to4 months

b.

Every 6 months

c.

Every 1 to 2 years

d.

Every 4 years

ANS: c

c. Clients between the ages of 40 and 64 years should have an eye examination every 1 to 2 years if there is a family history of glaucoma or if the client is of African ancestry.

a. This is not the recommended frequency of eye examinations for this age group.

b. This is not the recommended frequency of eye examinations for this age group.

d. This is not the recommended frequency of eye examinations for this age group.

REF: Text Reference: p. 1581

2. With advancing age, which of the following normal physiological changes in sensory function occurs?

a.

Decreased sensitivity to glare

b.

Increased number of taste buds

c.

Difficulty discriminating vowel sounds

d.

Decreased sensitivity to pain

ANS: d

d. Older adults experience tactile changes including declining sensitivity to pain, pressure, and temperature.

a. Older adults have an increased sensitivity to glare.

b. Older adults have a decreased number of taste buds.

c. Older adults have difficulty discriminating the consonants (z, t, f, g) and high-frequency sounds (s, sh, ph, k).

REF: Text Reference: p. 1570

3. The nurse teaches a client that prolonged use of the antibiotic streptomycin may result in:

a.

Damage to the auditory nerve

b.

Alteration in perception

c.

Optic irritation

d.

Loss of taste

ANS: a

a. Some antibiotics, such as streptomycin, gentamicin, and tobramycin, are ototoxic and can permanently damage the auditory nerve.

b. Narcotic analgesics, sedatives, and antidepressant medications can alter the perception of stimuli.

c. Chloramphenicol can irritate the optic nerve.

d. Prolonged use of streptomycin does not result in a loss of taste.

REF: Text Reference: p. 1576

4. Which of the following occupations poses the least risk for sensory alterations?

a.

Waiter

b.

Welder

c.

Computer programmer

d.

Construction worker

ANS: a

a. The waiter is at least risk for sensory alterations.

b. A welder is at risk for visual alterations.

c. A computer programmer is at risk for peripheral nerve injury.

d. A construction worker is at risk for hearing alterations.

REF: Text Reference: p. 1571

5. The nurse is working with a client with a moderate hearing impairment. To promote communication with this client, the nurse should:

a.

Use a louder tone of voice than normal

b.

Use visual aids such as the hands and eyes when speaking

c.

Approach a client quietly from behind before speaking

d.

Select a public area to have a conversation

ANS: b

b. To promote communication with the client who has a hearing impairment, the nurse should use visible expressions, such as speaking with the hands, face, or eyes.

a. A normal tone of voice and inflections of speech should be used when communicating with a client with a hearing impairment.

c. The nurse should get the clients attention and not startle the client when entering a room. The nurse should not approach a client from behind.

d. It is best to select a quiet environment without background noise to facilitate communication when a client is hearing impaired.

REF: Text Reference: p. 1585

6. The client has hyperesthesia apparently associated with a neurologic trauma. Which of the following is an appropriate nursing intervention in regard to the clients sense of touch?

a.

Reminding the client of the need to have frequent tactile contact

b.

Keeping the client loosely covered with sheets and blankets

c.

Allowing the client to lie motionless

d.

Using touch as a form of therapy

ANS: b

b. If a client is overly sensitive to tactile stimuli (hyperesthesia), the nurse must minimize irritating stimuli. Keeping bed linens loose to minimize direct contact with the client and protecting the skin form exposure to irritants are helpful measures.

a. Frequent tactile contact is not an appropriate intervention for the client with hyperesthesia.

c. Allowing the client to lie motionless is not an appropriate intervention for the client with hyperesthesia.

d. Using touch as a form of therapy would not be an appropriate nursing intervention for the client with hyperesthesia.

REF: Text Reference: p. 1583

7. The client has experienced a cerebrovascular accident (stroke) with resultant expressive aphasia. The nurse promotes communication with this client by:

a.

Speaking very loudly and slowly

b.

Speaking to the client on the unaffected side

c.

Using a picture chart for the clients responses

d.

Using hand gestures to convey information to the client

ANS: c

c. For the client with aphasia, the nurse can communicate by using a picture chart or communication board for the clients responses.

a. The nurse should not speak loudly and slowly to the client with expressive aphasia. The client is able to understand; this may seem patronizing to the client.

b. The nurse should not speak to the client on the unaffected side, as this will not improve communication.

d. Using hand gestures to convey information to the client may be helpful for the client with receptive aphasia, not expressive aphasia.

REF: Text Reference: p. 1585

8. The client was working in the kitchen and was splashed in the face with a caustic cleaning agent. His eyes were affected, and he was brought to the hospital for treatment. After cleansing and evaluation, his eyes were bandaged. When assisting this client who has temporary visual loss to eat, the nurse should:

a.

Feed the client the entire meal

b.

Allow the client to experiment with foods

c.

Orient the client to the location of the foods on the plate

d.

Encourage the family to feed the client

ANS: c

c. A meal tray can be set up as a clock. The visually impaired client can easily become oriented to the items after the nurse or family member explains each items location. This enables the client to perform self-care (feeding), which is essential for self-esteem.

a. The client should be allowed to feed himself or herself to maintain self-esteem.

b. Allowing the client to experiment with foods is not assisting the client in performing self-care.

d. The client should be allowed to feed himself or herself to maintain self-esteem.

REF: Text Reference: p. 1588

9. The nurse completes a safety assessment during a home visit to an older adult client. Of the following observations made by the nurse, the one that is of greatest concern for this client who has evidence of sensory impairment is:

a.

Low-pile carpeting throughout the home

b.

A handrail on the stairs that extends the full length

c.

Higher wattage iridescent lighting in all the rooms

d.

The gray/black settings on the stove handles

ANS: d

d. Sometimes settings on electrical appliances and equipment are highlighted only in black and white or shades of gray. Color contrasts help to distinguish settings. The greatest concern for safety for the client with sensory impairment is the gray/black setting on the stove handles.

a. Low-pile carpeting helps to prevent falls.

b. A handrail on the stairs that extends the full length is beneficial for preventing falls.

c. Higher-wattage iridescent lighting helps prevent glare and is an appropriate adaptation for visual loss.

REF: Text Reference: p. 1584

10. A client is legally blind in both eyes. Which of the following is the most appropriate statement for the nurse to make to the client regarding providing the client with assistance?

a.

I will walk in front of you, and you can hold onto my belt.

b.

I know that you must need me to be your sighted guide to get around in this facility.

c.

I will warn you of upcoming curbs or stairs.

d.

I will get you a wheelchair so that I can move you around safely.

ANS: c

c. To assist the client who is legally blind, the nurse should warn the client when approaching doorways or narrow spaces, including upcoming curbs or stairs.

a. To assist the client who is legally blind, the nurse should walk one-half step ahead and slightly to the side of the visually impaired person. The client can place his or her hand on the nurses forearm.

b. This is not the most appropriate response. The client may need orientation to the environment and extra time but should not be made to feel dependent on the nurse. Often sensorially impaired clients can help themselves, and it is essential that they do so for self-esteem.

d. Placing the client in a wheelchair is not the best response. The client who is able should be encouraged to ambulate.

REF: Text Reference: p. 1587

11. A 79-year-old client drives his car in the local areas near his home. The most appropriate driving tip for the nurse to give this client is:

a.

Go very, very slowly so you will have some chance of reacting.

b.

Take your time on long road trips when you are by yourself.

c.

Remember to keep your car maintained with regular checkups.

d.

To avoid sun glare, you should drive at night.

ANS: c

c. A safety tip the nurse can share with this client is to keep the car in good working condition.

a. The nurse should advise the client to go slowly, but not too slowly, for safety.

b. The nurse can offer the driving tip to drive in familiar areas, not on long road trips by themselves.

d. The client should be advised to avoid driving at dusk or at night.

REF: Text Reference: p. 1584

12. An older adult client in a nursing home has visual and hearing losses. The nurse is alert to which of the following signs that represents the effects of sensory deprivation?

a.

Diminished anxiety

b.

Improved task completion

c.

Altered spatial perception

d.

Decreased need for physical stimulation

ANS: c

c. Altered spatial perception is a sign of sensory deprivation.

a. Increased anxiety is a sign of sensory deprivation.

b. Poor task performance is a sign of sensory deprivation.

d. An increased need for physical stimulation is a sign of sensory deprivation.

REF: Text Reference: p. 1569

13. During a home safety assessment, the nurse identifies a number of hazards. Of the following hazards that are noted by the nurse, which one represents the greatest risk for this client with diabetic peripheral neuropathy?

a.

Improper water heater settings

b.

Absence of smoke detectors

c.

Cluttered walkways

d.

Lack of bathroom grab bars

ANS: a

a. Clients with impaired tactile sensation, such as the client with diabetic neuropathy, should be cautioned to have the setting on the water heater no higher than 120 F.

b. The greatest risk for the client with diabetic peripheral neuropathy is an improper water-heater setting, as the client would not be able to feel a setting that is too hot, and could therefore experience injury.

c. An absence of smoke detectors is not the greatest risk for the client with diabetic peripheral neuropathy. It would be of greater risk for the client who has an olfactory impairment.

d. Although a lack of bathroom grab bars may place a client at risk for falls, it is not the greatest risk for the client with diabetic peripheral neuropathy.

REF: Text Reference: p. 1585

14. The nurse in the pediatric clinic is checking the basic visual acuity of a 4-year-old child. The nurse should have the child:

a.

Use the standard Snellen chart

b.

Read a few lines from childrens book

c.

Follow the peripheral movement of an object

d.

Identify crayon colors

ANS: d

d. To assess basic visual acuity, the nurse should ask the client to identify crayon colors.

a. The Snellen chart may be used for the adult client, but would be less appropriate for the 4-year-old child.

b. The 4-year-old client may not be able to read. This would be an inaccurate assessment of visual acuity of a 4-year-old.

c. A 4-year-old client may have difficulty understanding following the movement of an object by using his or her peripheral vision.

REF: Text Reference: p. 1574

15. For a client with receptive aphasia, which one of the following nursing interventions is the most effective?

a.

Providing the client with a letter chart to use to answer complex questions

b.

Using a system of simple gestures and repeated behaviors to communicate

c.

Offering the client a notepad to write questions and concerns

d.

Obtaining a referral for a speech therapist

ANS: b

b. If the client has problems with comprehension, as in receptive aphasia, the nurse should use simple short questions, facial gestures, and repeated behaviors to communicate.

a. Providing a client with a letter chart would be more appropriate for the client with expressive aphasia. Questions should be simple, not complex, to aid comprehension.

c. A notepad would be appropriate for the client with expressive aphasia, not receptive aphasia.

d. Clients with expressive aphasia but not clients with receptive aphasia often require a speech therapist.

REF: Text Reference: p. 1585

16. The nurse recommends follow-up auditory testing for a child who was exposed in utero to:

a.

Excessive oxygen

b.

Diabetes

c.

Respiratory infection

d.

Rubella

ANS: d

d. Children at risk for hearing impairment include those who were exposed to rubella in utero.

a. Children at risk for visual impairment include those who received excessive oxygen as newborns.

b. Follow-up auditory testing is not necessary for a child who was exposed in utero to diabetes.

c. Follow-up auditory testing is not necessary for a child who was exposed in utero to a respiratory infection.

REF: Text Reference: p. 1581

17. The family of an older client asks the nurse how the stairways and hallways in the home may be enhanced to promote safety. In addition to extra lighting, the nurse recommends the use of paint and decorations that are:

a.

Red and yellow

b.

Black and white

c.

Brown and green

d.

Blue and purple

ANS: a

a. Brighter colors such as red, orange, and yellow are easier for the older adult to see.

b. Black and white colors are not the best recommendation for promoting safety in the older adult.

c. Perception of the colors blue, violet, and green usually declines with age.

d. Perception of the colors blue, violet, and green usually declines with age.

REF: Text Reference: p. 1583

18. The nurse is working with older adult clients in an extended care facility. To enhance the clients gustatory sense, the nurse should:

a.

Mix foods together

b.

Assist with oral hygiene

c.

Provide foods of similar texture and consistency

d.

Make sure foods are extremely spicy

ANS: b

b. Good oral hygiene keeps the taste buds well hydrated and will enhance the clients gustatory sense.

a. Taste perception is heightened if foods are eaten separately.

c. Taste perception is heightened if foods are differently textured.

d. Taste perception is heightened if foods are well seasoned, but not necessarily extremely spicy.

REF: Text Reference: p. 1583

19. A home safety measure specific for a client with diminished olfaction is the use of:

a.

Smoke detectors on all levels

b.

Extra lighting in hallways

c.

Amplified telephone receivers

d.

Mild water heater temperatures

ANS: a

a. A reduced sensitivity to odors means that the client may be unable to smell a smoldering fire. The client should use smoke detectors as a safety measure.

b. A home safety measure specific for a client with diminished vision is the use of extra lighting in hallways.

c. A home safety measure specific for a client with diminished hearing is the use of amplified telephone receivers.

d. A home safety measure specific for a client with reduced tactile sensation is having mild water heater temperatures.

REF: Text Reference: p. 1585

20. The nurse has completed the admission assessment for a client admitted to the hospitals subacute care unit. Of the following nursing diagnoses identified by the nurse, the one that takes the highest priority is:

a.

Social isolation

b.

Injury, risk for

c.

Adjustment, impaired

d.

Communication, impaired verbal

ANS: b

b. Safety is always a top priority.

a. The nursing diagnosis of Social isolation is not the highest priority.

c. The nursing diagnosis of Adjustment, impaired is not the highest priority.

d. The nursing diagnosis of Communication, impaired verbal is not the highest priority.

REF: Text Reference: p. 1580

21. While participating in a community auditory screening, the nurse is alert to the population that has the greatest prevalence of problems. The nurse is aware that hearing impairment is more common for:

a.

Caucasians

b.

Asian Americans

c.

African Americans

d.

Native Americans

ANS: a

a. Whites have more hearing impairment problems than do African Americans and Asian Americans.

b. Hearing impairment is not more common in Asian Americans.

c. African Americans are at greater risk for glaucoma, not for hearing impairment.

d. Otitis media is more prevalent among Native Americans than among whites.

REF: Text Reference: p. 1571

22. The nurse is visiting the day-care center for routine assessment of the children. After spending time with the children in one of the playrooms, the nurse suspects that a child has a visual deficit as a result of observing:

a.

Poor balance and gait

b.

An increase in weight

c.

Sitting and rocking back and forth

d.

A failure to respond when touched

ANS: c

c. Behaviors of children indicating a possible visual deficit include self-stimulation such as eye rubbing, body rocking, sniffing or smelling, and arm twirling.

a. Poor balance and gait may indicate an impairment of position sense in the adult.

b. A weight change may indicate a deficit in taste in the adult.

d. Failure to respond to touch may indicate a touch deficit in the adult.

REF: Text Reference: p. 1574

Copyright 2005 by Mosby, Inc. All rights reserved.

Leave a Reply