Chapter 49: Sensory Alterations Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

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:

1.

Every 3 to 4 months

2.

Every 6 months

3.

Every 1 to 2 years

4.

Every 4 years

ANS: 3

Clients between the ages of 40 and 64 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.

DIF: A REF: 1355 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Decreased sensitivity to glare

2.

Increased number of taste buds

3.

Difficulty discriminating vowel sounds

4.

Decreased sensitivity to pain

ANS: 4

Older adults experience tactile changes, including declining sensitivity to pain, pressure, and temperature. Older adults have an increased sensitivity to glare. Older adults have a decreased number of taste buds. Older adults have difficulty discriminating the consonants (z, t, f, g) and high-frequency sounds (s, sh, ph, k).

DIF: A REF: 1346 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Damage to the auditory nerve

2.

Alteration in perception

3.

Optic irritation

4.

Loss of taste

ANS: 1

Some antibiotics, such as streptomycin, gentamicin, and tobramycin, are ototoxic and can permanently damage the auditory nerve. Narcotic analgesics, sedatives, and antidepressant medications can alter the perception of stimuli. Chloramphenicol can irritate the optic nerve.

DIF: A REF: 1351 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Waiter

2.

Welder

3.

Computer programmer

4.

Construction worker

ANS: 1

The waiter is at least risk for sensory alterations. A welder is at risk for visual alterations. A computer programmer is at risk for peripheral nerve injury. A construction worker is at risk for hearing alterations.

DIF: A REF: 1356 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Use a louder tone of voice than normal

2.

Use visual aids such as the hands and eyes when speaking

3.

Approach a client quietly from behind before speaking

4.

Select a public area to have a conversation

ANS: 2

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 normal tone of voice and inflections of speech should be used when communicating with a client with a hearing impairment. 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. It is best to select a quiet environment without background noise to facilitate communication when a client is hearing impaired.

DIF: A REF: 1358 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Reminding the client of the need to have frequent tactile contact

2.

Keeping the client loosely covered with sheets and blankets

3.

Allowing the client to lie motionless

4.

Using touch as a form of therapy

ANS: 2

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 from exposure to irritants are helpful measures. Frequent tactile contact is not an appropriate intervention for the client with hyperesthesia. Allowing the client to lie motionless is not an appropriate intervention for the client with hyperesthesia. Using touch as a form of therapy would not be an appropriate nursing intervention for the client with hyperesthesia.

DIF: A REF: 1357 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Speaking very loudly and slowly

2.

Speaking to the client on the unaffected side

3.

Using a picture chart for the clients responses

4.

Using hand gestures to convey information to the client

ANS: 3

For the client with aphasia, the nurse can communicate using a picture chart or communication board for the clients responses. 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. The nurse should not speak to the client on the unaffected side, as this will not improve communication. Using hand gestures to convey information to the client may be helpful for the client with receptive aphasia, not expressive aphasia.

DIF: A REF: 1350 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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:

1.

Feed the client the entire meal

2.

Allow the client to experiment with foods

3.

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

4.

Assign ancillary personnel to feed the client

ANS: 3

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. The client should be allowed to feed himself to maintain self-esteem. Allowing the client to experiment with foods is not assisting the client in performing self-care. The client should be allowed to feed himself to maintain self-esteem.

DIF: A REF: 1361 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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:

1.

Low-pile carpeting throughout the home

2.

A handrail on the stairs that extends the full length

3.

Higher wattage incandescent lighting in all the rooms

4.

The gray/black settings on the stove handles

ANS: 4

Sometimes settings on electrical appliances and equipment are only highlighted 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. Low-pile carpeting helps to prevent falls. A handrail on the stairs that extends the full length is beneficial for preventing falls. Higher wattage incandescent lighting helps prevent glare and is an appropriate adaptation for visual loss.

DIF: C REF: 1356 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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?

1.

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

2.

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

3.

I will warn you of upcoming curbs or stairs.

4.

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

ANS: 3

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. 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. Often sensorially impaired clients can help themselves, and it is essential that they do so for self-esteem. The client who is able should be encouraged to ambulate.

DIF: A REF: 1360 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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:

1.

Go very, very slow so you will have some chance of reacting

2.

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

3.

Remember to keep your car maintained with regular checkups

4.

To avoid sun glare, you should drive at night

ANS: 3

A safety tip the nurse can share with this client is to keep the car in good working condition. The nurse should advise the client to go slow, but not too slow, for safety. The nurse can offer the driving tip to drive in familiar areas, not on long road trips by himself or herself. The client should be advised to avoid driving at dusk or at night.

DIF: A REF: 1356 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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?

1.

Diminished anxiety

2.

Improved task completion

3.

Altered spatial perception

4.

Decreased need for physical stimulation

ANS: 3

Altered spatial perception, increased anxiety, poor task performance, and an increased need for physical stimulation are all signs of sensory deprivation.

DIF: A REF: 1345 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Improper water heater settings

2.

Absence of smoke detectors

3.

Cluttered walkways

4.

Lack of bathroom grab bars

ANS: 1

Clients with impaired tactile sensation, as the client with diabetic neuropathy, should be cautioned to have the setting on the water heater no higher than 120 F. The greatest risk for the client with diabetic peripheral neuropathy is an improper water heater setting, because the client would not be able to feel a setting that is too hot and could therefore experience injury. 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. 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.

DIF: C REF: 1358 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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:

1.

Use the standard Snellen chart

2.

Read a few lines from a childrens book

3.

Follow the peripheral movement of an object

4.

Identify crayon colors

ANS: 4

To assess basic visual acuity, the nurse should ask the client to identify crayon colors. The Snellen chart may be used for the adult client but would be less appropriate for the 4-year-old child.

DIF: A REF: 1350 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

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

2.

Using a system of simple gestures and repeated behaviors to communicate

3.

Offering the client a notepad to write questions and concerns

4.

Obtaining a referral for a speech therapist

ANS: 2

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. 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. A notepad would be appropriate for the client with expressive aphasia, not receptive aphasia. Clients with expressive aphasia often require a speech therapist, not a client with receptive aphasia.

DIF: C REF: 1350 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Excessive oxygen

2.

Diabetes

3.

Respiratory tract infection

4.

Rubella

ANS: 4

Children at risk for hearing impairment include those who were exposed to rubella in utero. Children at risk for visual impairment include those who received excessive oxygen as a newborn.

DIF: A REF: 1356 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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:

1.

Red and yellow

2.

Black and white

3.

Brown and green

4.

Blue and purple

ANS: 1

Brighter colors such as red, orange, and yellow are easier for the older adult to see. Black and white colors are not the best recommendation for promoting safety in the older adult. Perception of the colors blue, violet, and green usually declines with age.

DIF: A REF: 1356 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Mix foods together

2.

Assist with oral hygiene

3.

Provide foods of similar texture and consistency

4.

Make sure foods are extremely spicy

ANS: 2

Good oral hygiene keeps the taste buds well hydrated and will enhance the clients gustatory sense. Taste perception is heightened if foods are eaten separately, are different textured, and are well seasoned.

DIF: A REF: 1350 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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

1.

Smoke detectors on all levels

2.

Extra lighting in hallways

3.

Amplified telephone receivers

4.

Mild water heater temperatures

ANS: 1

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. A home safety measure specific for a client with diminished vision is the use of extra lighting in hallways. A home safety measure specific for a client with diminished hearing is the use of amplified telephone receivers. A home safety measure specific for a client with reduced tactile sensation is having mild water heater temperatures.

DIF: A REF: 1358 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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:

1.

Social isolation

2.

Risk for injury

3.

Risk-prone health behavior

4.

Impaired verbal communication

ANS: 2

Safety is always a top priority.

DIF: C REF: 1352 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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:

1.

Whites

2.

Asian Americans

3.

African Americans

4.

Native Americans

ANS: 1

Whites have more hearing impairment problems than African Americans and Asian Americans. African Americans are at greater risk for glaucoma, not for hearing impairment. Otitis media is more prevalent among Native Americans than among whites.

DIF: A REF: 1346 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

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:

1.

Poor balance and gait

2.

An increase in weight

3.

Sitting and rocking back and forth

4.

A failure to respond when touched

ANS: 3

Behaviors of children indicating a possible visual deficit include self-stimulation such as eye rubbing, body rocking, sniffing or smelling, and arm twirling. Poor balance and gait may indicate an impairment of position sense in the adult. A weight change may indicate a deficit in taste in the adult. Failure to respond to touch may indicate a touch deficit in the adult.

DIF: A REF: 1350 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

23. A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety even though the client has been reassured that his or her condition is improving and discharge to the unit will be occurring soon. The cause of the clients emotional state is a result of:

1.

Fear of death

2.

Social isolation

3.

Sensory overload

4.

Anxiety disorder

ANS: 3

The acutely ill client easily falls victim to sensory overload. The client in constant pain or who undergoes frequent monitoring of vital signs or who has irritation from drainage tubes is at risk.

DIF: A REF: 1345 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

24. A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety, and the nurse believes the client is experiencing sensory overload. Which of the following interventions will be most therapeutic in assisting the client?

1.

Limiting interaction with the client to the safe minimum

2.

Moving the client to a space furthest from the nursing station

3.

Keeping the clients lights dimmed and curtains partially drawn

4.

Asking the clients health care provider to consider early discharge to the unit

ANS: 3

Constant reorientation and control of excessive stimuli becomes an important part of the clients care. Although the remaining options may have value, they are not the most therapeutic because external stimulation is the most likely cause of the problem.

DIF: C REF: 1345 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

25. The wife of a 70-year-old client who is recuperating at home from hip replacement surgery expresses a concern to the nurse that He must be getting depressed. He just doesnt interact with people like he used to. Which of the following is the nurses most therapeutic response?

1.

Are there any other signs of depressions?

2.

Does he usually enjoy interacting with visitors?

3.

Do you think he may be having difficulty hearing what people are saying to him?

4.

Well he could be. Do you want me to see if his health care provider will order an antidepressant?

ANS: 3

A concern with normal age-related sensory changes is that older adults with a deficit are sometimes inappropriately diagnosed with dementia or depression. The remaining options assume that depression may be the cause of his personality change.

DIF: C REF: 1345 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

26. A 54-year-old client expresses concern about her weakening sense of smell to the nurse during an admission interview. The nurses most therapeutic response is:

1.

I dont think it is anything to worry about, but you could mention it to your health care provider

2.

That is really a fairly common complaint of people your age; I dont think there is anything to worry about

3.

As long as you can smell things like smoke if there is a fire, I think it is something you need to get used to

4.

As long as you can smell things like smoke if there is a fire, I think it is something you need to get used to

ANS: 4

Gustatory and olfactory changes begin around age 50 and include a decrease in the number of taste buds and a decrease in the number of sensory cells in the nasal lining. Reduced taste discrimination and reduced sensitivity to odors are common. The remaining options do not provide the most likely cause of the sensory deficit.

DIF: C REF: 1345-1346 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

27. The daughter of a client recently admitted to a skilled nursing facility shares with the nurse that she is concerned about how disinterested her mother seems in everyone and everything around her. The most therapeutic response by the nurse is:

1.

Bring something from home for her to display in her room

2.

It is most likely just her way of adjusting to leaving her home

3.

Many of the residents have this problem when they first come here

4.

Just give her time to adjust; shell get more involved in a few days

ANS: 1

Meaningful stimuli reduce the incidence of sensory deprivation. The presence or absence of meaningful stimuli influences alertness and the ability to participate in care. The remaining options simply attempt to explain away the behavior.

DIF: C REF: 1346 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

28. The nurse is discussing vision and hearing health with a group of senior citizens. Which of the following individuals should be given special encouragement to have regular eye screenings for the presence of glaucoma?

1.

An African American with hypertension

2.

An Asian with osteoarthritis in the hands

3.

A white with peripheral vascular disease

4.

A Hispanic with type 2 diabetes

ANS: 1

Glaucoma is almost 3 times as common in African Americans as in white Americans. The remaining options represent ethnic groups with eye-related risk factors but not necessarily for glaucoma.

DIF: C REF: 1346 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

29. Which of the following statements made by a client diagnosed with diabetes shows the most informed understanding of the effect of the disease on optic health?

1.

The scariest part about having diabetes is the increased possibility of losing my eyesight.

2.

I have my eyes checked yearly to be aware of any retinopathy that may be developing.

3.

If I do a good job of keeping my blood sugars in line, I wont run such a risk for eye problems.

4.

I try to keep my A1C below 7 so I can minimize the bad effects of hyperglycemia on my eyes.

ANS: 2

Hispanic Americans have an increased incidence of diabetic retinopathy. Although the remaining options reflect a general understanding, they are not as specific nor do they mention the specific self-care measures related to vision.

DIF: C REF: 1346 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

30. The nurse and a 69-year-old client are discussing the clients report of Not hearing as well as I used to; I must be getting old. Which of the following nursing responses is most therapeutic regarding the clients assumption of the cause of the diminished hearing?

1.

What makes you think you dont hear as well as you used to?

2.

Well, hearing loss does seem to be more of a problem as we age.

3.

You may be right, but I suggest you see an otolaryngologist just to be sure.

4.

Do you turn the television up louder, or is it difficult to hear on the telephone?

ANS: 3

Be careful to not automatically assume that a clients sensory problem is related to advancing age. The suggestion to see a otolaryngologist is the most therapeutic because it provides a means to rule out more serious conditions. The remaining options either attempt to further identify the symptoms of the clients problems or simply agree with the theory of aging.

DIF: C REF: 1345 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

31. The nurse and a 62-year-old client are discussing the clients sense of hearing. Which of the following assessment questions is most likely to launch a conversation concerning the clients ability to hear effectively?

1.

Do you think you have a hearing problem?

2.

Do you hear as well as you did 5 years ago?

3.

Would you rate your hearing as excellent, good, fair, poor, or bad?

4.

Can you tell me when you believe you started to experience a hearing loss?

ANS: 3

During the history, it is useful to assess the clients self-rating for a sensory deficit. You can simply say, Rate your hearing as excellent, good, fair, poor, or bad. Then, based on the clients self-rating, explore the clients perception of a sensory loss more fully. The remaining options are either closed-ended questions (which do not encourage communication) or an assumption of hearing loss.

DIF: C REF: 1348 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

32. The primary safety issue related to the presence of a taste deficit in a young child is there will most likely be:

1.

Little incentive to hydrate

2.

No social connection to food

3.

Limited food experimentation

4.

Little discretion for ill-tasting substances

ANS: 4

The inability to taste ill-flavored substances may well lead to accidental poisoning.

DIF: C REF: 1350 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

33. It has been determined that a vision problem has contributed to a clients ability to provide self-care regarding bathing, dressing, and toileting. The initial nursing responsibility regarding these deficits is to:

1.

Educate the clients family regarding the existing limitations so as to secure their support in meeting needs regarding activities of daily living (ADLs)

2.

Arrange for in-home services to facilitate the clients ability to remain as independent as possible regarding ADLs

3.

Provide the in-home care provider with sufficient information regarding the clients sensory deficits regarding ADLs

4.

Provide sufficient client education regarding the in-home services available to help with ADL needs once discharge has occurred

ANS: 2

If a sensory alteration impairs a clients functional ability, providing resources within the home is a necessary part of discharge planning. Although the other options are not inappropriate, they are not the initial priority.

DIF: C REF: 1349 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

34. The nurse is discussing eye safety with a group of adults who regularly work around power tools. Which of the following questions should be the initial follow-up to the nurses inquiry, Do you own safety glasses?

1.

Are they in good working order?

2.

How long have you been using them?

3.

Do you wear them each time you use your tools?

4.

What do you think the advantage is to wearing them?

ANS: 3

Although all the options are relevant to the issue of eye safety, the initial follow-up should relate to the clients habit of actually wearing the safety device.

DIF: C REF: 1349 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

35. The nurse is preparing a 70-year-old visually impaired male client for home discharge. Which of the following nursing actions will have the greatest impact on the clients safety related to medication administration?

1.

Evaluate the clients ability to read the frequency and dosage information on his medication bottles.

2.

Watch the client demonstrate the appropriate method for splitting his morning medication in half.

3.

Observe the client open and pour out the appropriate number of pills required for his morning medications.

4.

Have the client restate the administration schedule and prescribed dosage of each of his home medications.

ANS: 1

Ask the client to read a label to determine if the client is able to read the dosage and frequency. Although the other options are appropriate interventions, the primary concern is the ability to read the instructions in light of the visual impairment.

DIF: C REF: 1349 OBJ: Analysis

TOP: Nursing Process: Evaluation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

36. The nurse is caring for a newly admitted client who is aphasic. The nurse most therapeutically addresses the communication issue by:

1.

Evaluating the clients ability to express his or her needs by writing

2.

Asking the client how he or she wants to communicate with the staff

3.

Giving the client a pad and a pencil with which to communicate

4.

Providing the client with an orientation to the use of the call bell

ANS: 2

Determine whether the client has developed a sign language system or symbols to communicate needs. Every client should be oriented to the proper use of the call bell, and the remaining options assume that writing will be the clients preferred method of communication.

DIF: C REF: 1351 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

37. Which of the following statements made by the nurse shows the greatest insight into the possible causes of a hearing-impaired clients irritability?

1.

I know he doesnt hear well, but I wonder if his increased lack of patience today has to do with being in pain.

2.

Not being able to hear us properly appears to be making him irritable today. See if he has his hearing aid turned off.

3.

His hearing aids must need new batteries; he is just so irritable and impatient today.

4.

He is certainly irritable today, but maybe it doesnt have to do with his poor hearing.

ANS: 1

Always remember that factors other than sensory deprivation or overload cause impaired perception and emotional irritation (e.g., medications or pain). Although one of the options presents a general suspicion that the cause of the problem may not be his hearing impairment, the remaining options assume that it is the cause of his irritation.

DIF: C REF: 1351 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

38. The nurse notes that the 43-year-old male blind client who has had a stroke is not having difficulty recognizing an object by touch. This sense is known as:

1.

Stereognosis

2.

Auditory

3.

Gustatory

4.

Olfactory

ANS: 1

Stereognosis is a sense that allows a person to recognize an objects size, shape, and texture. The auditory sense is the sense of hearing. The gustatory sense is the sense of tasting. The olfactory sense is the sense of smelling

DIF: C REF: 1350 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

39. The 25-year-old male client who has been in the trauma intensive care unit (ICU) for 3 weeks is confused and agitated. The nurse knows that this can happen to clients in an ICU setting due to:

1.

Boredom

2.

Sensory overload

3.

Pain

4.

A lack of stimulation

ANS: 2

When a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli, sensory overload occurs. Excessive sensory stimulation prevents the brain from appropriately responding to or ignoring certain stimuli. Because of the multitude of stimuli leading to overload, the person no longer perceives the environment in a way that makes sense

DIF: A REF: 1349 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

40. The 85-year-old female client has moved to an assisted living apartment so that she can remain independent yet have some limited assistance with her ADLs. Which of the following suggestions should the nurse make that would be most appropriate to reduce sensory deprivation?

1.

Provide pictures of the clients family.

2.

Purchase all-new furnishings.

3.

Suggest that the client take all her meals in her apartment until she gets the chance to know her neighbors better.

4.

Ask family and friends to wait a few days to visit until the client has an opportunity to settle in.

ANS: 1

Meaningful stimuli reduce the incidence of sensory deprivation. In the home, meaningful stimuli include pets, music, television, pictures of family members, and a calendar and clock Keeping as many of her own furnishings as possible may help make her new environment more like home. The presence of others offers positive stimulation. The ability to discuss concerns with loved ones is an important coping mechanism for most people. Therefore the absence of meaningful conversation will result in feelings of isolation, loneliness, anxiety, and depression for the client. Often, this is not apparent until behavioral changes occur.

DIF: A REF: 1343 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

41. A 47-year-old male client has come in to his primary health care providers office for his annual checkup. The client shares with the nurse that his wife thinks he is suffering from hearing loss. Which of the following responses by the nurse would be most appropriate?

1.

You are approaching an age when it is common to start having some hearing loss.

2.

Do you work in a noisy environment?

3.

You dont seem to have hearing problems to me.

4.

Has anyone else noticed that you are having hearing problems?

ANS: 2

In the case of sensory alterations you need to integrate knowledge of the pathophysiology of sensory deficits, factors that affect sensory function, and therapeutic communication principles. A persons occupation places him or her at risk for hearing, visual, and peripheral nerve alterations. Individuals who have occupations involving exposure to high noise levels (e.g., factory or airport workers) are at risk for noise-induced hearing loss and need to be screened for hearing impairments. Hazardous noise is common in work settings as well as recreational activities. Be careful to not automatically assume that a clients sensory problem is related to advancing age. For example, adult sensorineural hearing loss is often due to exposure to excess and prolonged noise or metabolic, vascular, and other systemic alterations. Collect a history that also assesses the clients current sensory status and the degree to which a sensory deficit affects the clients lifestyle, psychosocial adjustment, developmental status, self-care ability, health promotion habits, and safety.

DIF: A REF: 1345 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

42. Which of the following safety measures is most important for the nurse to implement for a hospitalized client with a visual impairment?

1.

Orient the client to the room.

2.

Open the window blinds to let in light.

3.

Keep the clients door to the room open so that he or she can be visualized.

4.

Keep all four side rails up to remind the client not to get up on his or her own.

ANS: 1

Clients with serious visual impairment need to feel comfortable in knowing the boundaries of the immediate environment. Normally we see physical boundaries within a room. The blind or severely visually impaired often touch the boundaries or objects to gain a sense of their surroundings. The client needs to walk through a room and feel the walls to establish a sense of direction. Help clients by explaining objects within the room, such as furniture or equipment. It takes time for the client to absorb a rooms arrangement. The client often needs to reorient again, with your explaining the location of key items. Glare from the window may actually cause more visual problems. The client may prefer to have the door to the room closed for privacy. Putting all four side rails up on the bed increases the risk for falls.

DIF: B REF: 1344-1345 OBJ: Application

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

43. Following a brain attack, the 45-year-old female client was very confused She was having difficulty responding appropriately to the nurse and to her family members. The clients daughter was concerned that her mother was suffering from a mental breakdown, even though she had no history of mental illness. The best information that the nurse can share with the clients daughter is:

1.

Your mother appears to have aphasia as a result of her stroke.

2.

Your mother will be just fine in no time.

3.

Your mother has been through a lot as a result of her stroke.

4.

We can have a psychiatric workup done if you would like.

ANS: 1

The most common language disorder following a stroke is aphasia. As a result of a disruption in blood flow to the brain, the speech center becomes damaged, altering a persons ability to either use or understand spoken words. Depending on the type of aphasia, the inability to communicate is often frustrating and frightening. Initially you need to establish very basic communication and recognize that aphasia does not indicate intellectual impairment or degeneration of personality. Explain situations and treatments that are pertinent to the client because he or she is able to understand the speakers words. Because a stroke often causes partial or complete paralysis of one side of the clients body, an aphasic client will need special assistive devices. There are communication boards that have been developed for several levels of disability. Sensitive pressure switches, activated by the touch of an ear, nose, or chin, control electronic communication boards. Clients who have had a stroke usually acquire referrals to speech therapists to develop appropriate rehabilitation plans.

DIF: C REF: 1349 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

MULTIPLE RESPONSE

1. The nurse is discussing vision changes that normally occur with aging with a group of older adults. Which of the following conditions should be included in the discussion? (Select all that apply.)

1.

Poor night vision

2.

Increased optical floaters

3.

Reduced peripheral vision

4.

Reduced depth perception

5.

Increased sensitivity to glare

6.

Diminished color perception

ANS: 1, 3, 4, 5, 6

Normal visual changes associated with aging include reduced visual fields, increased glare sensitivity, impaired night vision, reduced depth perception, and color discrimination. Floaters are not age related.

DIF: C REF: 1359 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

2. Which of the following physical assessments are essential when attempting to determine the presence of sensory deficits in an older adult client? (Select all that apply.)

1.

Vision

2.

Hearing

3.

Smell

4.

Taste

5.

Touch

6.

Gait

ANS: 1, 2, 3, 4, 5

To identify sensory deficits and their severity, assess vision, hearing, olfaction, taste, and the ability to discriminate light touch, temperature, pain, and position. Although gait may be affected by a sensory deficit, it is not considered a sensory deficit by itself.

DIF: A REF: 1359 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Psychosocial Integrity/Sensory/Perceptual Alterations Systems

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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