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Flashcards in Chapter 30 Sensory Deck (23)
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1
Q

A patient must place his hand on the wall to keep his balance when walking. He leans when sitting and has difficulty knowing when his body is vertical and sensing the position of his body in space. Which type of receptor is probably involved?

1) Photoreceptors
2) Chemoreceptors
3) Proprioceptors
4) Thermoreceptors

A

Answer:
3) Proprioceptors

Rationale:
Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. Photoreceptors located in the retina of the eyes detect visible light. Chemoreceptors are located in the taste buds and epithelium of the nasal cavity. They play a role in taste and smell. Thermoreceptors in the skin detect variations in temperature.

2
Q

Which medication might blunt a patient’s perception of various kinds of stimuli?

1) Furosemide (Lasix)
2) Metoprolol (Lopressor)
3) Morphine sulfate
4) Metoclopramide (Reglan)

A

Answer:
3) Morphine sulfate

Rationale:
Central nervous system depressants, such as the opioid analgesic morphine, blunt the perception of stimuli. Furosemide, metoprolol, and metoclopramide do not affect the patient’s perception of stimuli.

3
Q

A patient complains, “Everything tastes so bland. I add salt, pepper, and sugar to everything just to make it so I can taste it.” Which nutrient deficiency might be responsible for his problem? Select all that apply.

1) Vitamin A
2) Vitamin B12
3) Iron
4) Zinc

A

Answer:

2) Vitamin B12
4) Zinc

Rationale:
Deficiencies in vitamin B12 or zinc may cause diminished taste. Deficiencies in vitamin A and iron do not cause diminished taste.

4
Q

After sustaining an eye injury in a baseball game, a patient complains of blurred and distorted vision. Which visual deficit is this patient most likely experiencing?

1) Macular degeneration
2) Astigmatism
3) Strabismus
4) Glaucoma

A

Answer:
2) Astigmatism

Rationale:
Astigmatism is caused by irregular curvature of the cornea or lens that results from injury, infection, or an inherited trait. Astigmatism causes blurred and distorted vision.

5
Q

A patient who has been unable to sleep for several nights has experienced a change in mental status. He does not know what day it is, or where he is. His speech and movements are slowed, and he seems dazed and stupefied. He cannot follow simple directions such as, “Hold out your hand.” Which nursing diagnosis is most appropriate for this patient?

1) Chronic Confusion
2) Acute Confusion
3) Impaired Environmental Interpretation Syndrome
4) Impaired Memory

A

Answer:
2) Acute Confusion

Rationale:
Acute Confusion is the abrupt onset of transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, and the sleep-wake cycle. This diagnosis is used for those who exhibit signs of sleep deprivation. Chronic Confusion may be used for patients with Alzheimer’s disease. Impaired Environmental Interpretation Syndrome is used when there is a lack of consistent orientation to person, place, time, or circumstances over more than 3 to 6 months. Impaired Memory is the inability to remember or recall bits of information.

6
Q

A patient in a nursing home is deaf and nearly blind. He is confined to bed most of the time. Which of the following interventions would help to promote optimal sensory function?

1) Keep the television on during waking hours.
2) Put colorful artwork on the walls.
3) Provide aromatherapy for him.
4) Keep the room dark and quiet.

A

Answer:
3) Provide aromatherapy for him.

Rationale:
Aromatherapy would stimulate the patient’s sense of smell, which apparently is still intact. When one sense is impaired, it is important to stimulate others. This patient is at risk for sensory deprivation because he has no auditory stimuli, limited visual and tactile stimuli, and because of being confined to bed, limited social interaction. Nursing interventions should focus on providing appropriate stimuli. Although television can provide stimulation when used appropriately, it is meaningless when overused. In addition, this patient could not hear or see it. He would not be able to see artwork on the walls well enough for it to provide stimulation. Keeping the room dark and quiet would further reduce the limited stimuli from light that the patient is able to perceive. Furthermore, “quiet” would be irrelevant for a patient who is deaf.

7
Q

The nurse in the intensive care unit is developing a seizure precaution plan for a patient with a history of epilepsy. What is the most important goal for this patient?

1) Protection from injury during seizures
2) Prevention of seizure activity
3) Padding for siderails, headboard, and footboard
4) Assessment for an aura prior to the seizure

A

Answer:
1) Protection from injury during seizures

Rationale:
The goal of seizure precautions is to protect the patient from injury during the seizure event. Seizure precautions are instituted for patients with a new diagnosis of a seizure disorder, any seizure activity within the past 12 months, frequent seizure activity, history of head trauma, and withdrawal from antiseizure medication. Although the nurse can attempt to prevent seizure activity possibly through the use of medications, the nurse can fully prevent seizures using nonpharmacological measures. Assessing a patient for an aura prior to a seizure is assessment (not a goal). Padding side rails, headboard, and footboard are nursing interventions—not nursing goals for care.

8
Q

A patient with Parkinson’s disease is at risk for which complication?

1) Impaired kinesthesia
2) Macular degeneration
3) Seizures
4) Xerostomia

A

Answer:
1) Impaired kinesthesia

Rationale:
Patients with Parkinson’s disease are at risk for impaired kinesthesia, placing them at risk for falling. Drooling, not excessive dry mouth (xerostomia) is common with Parkinson’s disease. Seizures and macular degeneration are not associated with Parkinson’s disease.

9
Q

A patient is admitted with an exacerbation of asthma. Which factor places the patient at highest risk for sensory overload?

1) Administering albuterol for bronchodilation as needed
2) Administering a tranquilizer intravenously every 2 hours
3) Delivering oxygen at 6 L/min via nasal cannula
4) Maintaining complete bedrest in a quiet, dimly lit room

A

Answer:
1) Administering albuterol (a central nervous stimulate) every as needed

Rationale:
Medications that stimulate the central nervous system, such as albuterol, place the patient at risk for sensory overload. A tranquilizer and a quiet, darkened room may help the patient to relax, thus preventing sensory overload. If the patient’s oxygen needs are met with oxygen at 6 L/min via nasal cannula, the patient should not experience sensory overload related to oxygen therapy alone. Oxygen deprivation can lead to air hunger and feelings of anxiety.

10
Q
You are using the Glasgow Coma Scale to assess a client's level of consciousness (LOC). Which of the following responses to stimuli does this scale assess?
SELECT ALL THAT APPLY.
1) Brainstem reflexes
2) Eye responses
3) Respirations
4) Motor responses
5) Verbal responses
6) Heart rate responses
A

ANS - 2,4,5

Feedback 1: The Full Outline of Un-Responsiveness (FOUR) scale, not the Glasgow scale, assesses brainstem reflexes and respirations.
Feedback 2: The Glasgow Coma Scale is commonly used to assess LOC. It assesses eye, motor, and verbal responses.
Feedback 3: The Full Outline of Un-Responsiveness (FOUR) scale, not the Glasgow scale, assesses brainstem reflexes and respirations.
Feedback 4: The Glasgow Coma Scale is commonly used to assess LOC. It assesses eye, motor, and verbal responses.
Feedback 5: The Glasgow Coma Scale is commonly used to assess LOC. It assesses eye, motor, and verbal responses.
Feedback 6: The Glasgow Coma Scale does not assess for heart rate responses.

11
Q

While you are performing a focused nursing assessment of a patient’s hearing, he mentions that lately he has begun to hear a ringing sound in his ears at night when he lies down to sleep. Which of the following hearing deficits is this client most likely experiencing?

1) Presbycusis
2) Tinnitus
3) Nerve deafness
4) Otitis media

A

ANS - 2

Tinnitus is a term used to describe ringing in the ears. Most tinnitus comes from damage to the microscopic endings of the nerve in the inner ear, for example, trauma, turbulent blood flow, hypertension, ear infection, medications, otosclerosis, or arthritic changes of the bones of the ear.

12
Q

As you are walking along the sidewalk, you feel your cell phone vibrating in your pocket. Which of the following receptors allow you to receive this stimulus?

1) Mechanoreceptors
2) Thermoreceptors
3) Proprioceptors
4) Chemoreceptors

A

ANS - 1

Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.
Thermoreceptors in the skin detect variations in temperature.
Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable us to sense the position of our body in space (proprioception).
Chemoreceptors for taste are located in our taste buds.

13
Q

You are caring for a client with severely limited vision. Which of the following interventions should you make?
SELECT ALL THAT APPLY.
1) Provide an uncluttered environment.
2) Provide closed-caption television.
3) Consider conversion to text-telephone service.
4) Consider books on tape or in Braille for the client.
5) Avoid distracting the client’s guide dog.
6) Keep the bed in a high position.

A

ANS - 1,4,5

Feedback 1: For clients with severely limited vision, provide an uncluttered environment and do not rearrange furniture.
Feedback 2: For clients with a hearing deficit, not severely limited vision, provide closed-caption television.
Feedback 3: For clients with a hearing deficit, not severely limited vision, consider conversion to text-telephone service.
Feedback 4: For clients with severely limited vision, consider books on tape or in Braille.
Feedback 5: For clients with severely limited vision, avoid distracting the client’s guide dog.
Feedback 6: For clients with severely limited vision, keep the bed in a low, not high, position.

14
Q
You are caring for a 12-year-old boy with autism who was recently admitted to the hospital. His mother looks worried, and when you ask her what's wrong, she says, "His senses get overwhelmed easily, and there's so much going on here." Which of the following are signs of sensory overload, which you should observe for in this client?
SELECT ALL THAT APPLY.
1) Depression
2) Preoccupation with heart palpitations
3) Anxiety
4) Inability to concentrate
5) Restlessness
6) Delusions
A

ANS - 3,4,5

Feedback 1: Depression is a sign of sensory deprivation, not overload.
Feedback 2: Preoccupation with somatic complaints, such as heart palpitations, is a sign of sensory deprivation, not overload.
Feedback 3: Anxiety is a sign of sensory overload.
Feedback 4: Inability to concentrate is a sign of sensory overload.
Feedback 5: Restlessness is a sign of sensory overload.
Feedback 6: Delusions are a sign of sensory deprivation, not overload.

15
Q

You are performing a focused physical examination of a client with diabetes. Which of the following sensory deficits, associated with this client’s condition, should concern you most?

1) Blindness
2) Hearing impairment
3) Dyskinesia
4) Anosmia

A

ANS - 1

Some diseases affect specific sensory organs. For example, diabetic retinopathy is the leading cause of blindness among adults aged 20 to 74 years.
Hearing impairment is not associated with diabetes.
Dyskinesia, or difficulty moving, is not associated with diabetes.
Anosmia, or lack of the sense of smell, is not associated with diabetes.

16
Q
You are assessing a client's risk for sensory deprivation. Which of the following situations would increase the client's risk?
SELECT ALL THAT APPLY.
1) Being on a sedative
2) Having a traumatic brain injury
3) Being physically active
4) Having a hearing impairment
5) Working in a busy airport
6) Being a non-English-speaking visitor to the United States
A

ANS - 1,2,4,6

Feedback 1: Impaired sensory reception (e.g., neurological injury, dementia, depression, sleep deprivation, sensory losses, and central nervous system depressant medications) is a risk factor for sensory deprivation.
Feedback 2: Inability to transmit or process stimuli as a result of a nerve or brain injury is a risk factor for sensory deprivation.
Feedback 3: Restricted mobility, not being physically active, is a risk factor for sensory deprivation.
Feedback 4: Sensory deficits (e.g., vision, hearing) are risk factors for sensory deprivation.
Feedback 5: A nonstimulating, monotonous environment is a risk factor for sensory deprivation. A busy airport would be a stimulating environment.
Feedback 6: Being from a different culture and unable to interpret received cues is a risk factor for sensory deprivation.

17
Q

You are working with a new nurse who complains about the constant beeping of a patient’s heart monitor. She says to you, “How do you stand hearing that all day long?” You reply, “I don’t even notice it anymore unless there is an unexpected change.” Which of the following factors is most affecting your response to the beeping in this case?

1) Intensity
2) Contrast
3) Adaptation
4) Previous experience

A

ANS - 3

An intense stimulus excites more receptors, leading to a greater response.

Contrast is also stimulating. Imagine being outside in cold, windy weather. If you enter an unheated garage, you instantly feel warmer because the building blocks the wind. If you then go inside a room with a blazing fireplace, you will need to take off layers of clothing rapidly because the contrast in temperature will make you feel hot.

Often we take stimuli for granted. Recall your first clinical experience. Did you notice the noise and activity on the unit? Nurses become accustomed to the noise, lights, activity, and even alarms and are able to “tune them out.” These stimuli are new to many patients, so they notice them and may have difficulty resting.

Prior experience with a stimulus affects ongoing responses to the same stimulus. Have you ever seen a patient scrunch her eyes, grit her teeth, or turn away from an injection before you are even ready to give it? This may mean that she has memory of a prior negative experience with injections.

18
Q

As you prepare to take a client’s blood pressure, you reach back and without looking find the stethoscope hanging on the wall behind you, grab it, and place the ear pieces in your ears. Which of the following receptors allowed you to perform this action?

1) Mechanoreceptors
2) Thermoreceptors
3) Proprioceptors
4) Chemoreceptors

A

ANS - 3

Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.
Thermoreceptors in the skin detect variations in temperature.
Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable us to sense the position of our body in space (proprioception).
Chemoreceptors for taste are located in our taste buds.

19
Q

You are caring for a client with macular degeneration who lives alone. Which of the following nursing diagnoses would be most appropriate for this client?

1) Risk for Falls r/t visual impairment
2) Risk for Injury r/t reduced tactile sensation
3) Bathing Self-Care Deficit r/t kinesthetic impairment
4) Deficient Diversional Activity r/t reluctance to be in social situations because of hearing impairment

A

ANS - 1

Macular degeneration is the loss of central vision due to damage to the macula lutea, the central portion of the retina. Because the client lives alone and has a visual impairment, he would be at risk for falls.
Macular degeneration is a visual impairment, not a tactile impairment.
Macular degeneration is a visual impairment, not a kinesthetic impairment.
Macular degeneration is a visual impairment, not a hearing impairment.

20
Q

You hand a form to a middle-aged client to sign, and the client squints at it, holds it at arm’s length, and then says, “Hold on—I need to get my reading glasses to see this. My vision’s just getting terrible these days.” Which of the following visual deficits is this client most likely experiencing?

1) Myopia
2) Hyperopia
3) Presbyopia
4) Glaucoma

A

ANS - 3

Myopia, or nearsightedness, means that the patient is able to see close objects well but not distant objects.
Hyperopia, or farsightedness, implies that the eye sees distant objects well; however, near vision is impaired. Although it is possible this client has hyperopia, the fact that she is middle aged and that she mentions that the condition has progressed recently indicates that it is more likely to be presbyopia.
Presbyopia is a change in vision associated with aging. The lens becomes less elastic and less able to accommodate to near objects. If you’re older than age 40 years, there’s a good chance you may be experiencing this problem.
Glaucoma is a type of vision loss caused by increased pressure in the anterior cavity of the eyeball that distorts the shape of the cornea and shifts the position of the lens, resulting in loss of peripheral vision.

21
Q

You are caring for a client who is at risk for sensory deprivation. Which of the following interventions should you make?
SELECT ALL THAT APPLY.
1) Tape some artwork on the wall that the client’s granddaughter made for her.
2) Clean the client’s eyeglasses and encourage her to wear them when awake.
3) Turn off the television.
4) Offer the client a back rub.
5) Dim the lights in the room.
6) Remove fresh flowers or other heavily scented items from the room.

A

ANS - 1,2,4

Feedback 1: For visual stimulation, put artwork on the walls, furnish colorful pajamas and robes, and place pictures or flowers where the patient can see them.
Feedback 2: For visual stimulation, help the patient with glasses to apply them whenever she is not sleeping. Make sure eyeglasses are clean and in good repair. This will allow the patient to receive available stimuli.
Feedback 3: Turning off the television reduces visual and auditory stimuli and is an appropriate intervention for a client with sensory overload, not for a client with sensory deprivation.
Feedback 4: To provide tactile stimulation, you may want to hold a patient’s hand while talking or provide a back rub with morning and bedtime care.
Feedback 5: Dimming the lights in the room reduces visual stimuli and is an appropriate intervention for a client with sensory overload, not for a client with sensory deprivation.
Feedback 6: Removing fresh flowers or other heavily scented items from the room reduces olfactory stimuli and is an appropriate intervention for a client with sensory overload, not for a client with sensory deprivation.

22
Q

You are assessing a client’s level of consciousness. You begin by speaking to the client, but the client does not respond. Which of the following should you do next in your assessment?

1) Wave at the client to get his attention.
2) Pass smelling salts beneath the client’s nose.
3) Tap on the client’s hand.
4) Shout the client’s name.

A

ANS - 3

An alert client will respond to auditory stimuli. If the client does not respond, progress to tactile and then painful stimuli—not visual stimuli.

An alert client will respond to auditory stimuli. If the client does not respond, progress to tactile and then painful stimuli—not olfactory stimuli.

An alert client will respond to auditory stimuli. If the client does not respond, progress to tactile and then painful stimuli.

An alert client will respond to auditory stimuli. If the client does not respond, progress to tactile and then painful stimuli.

23
Q

You are caring for a client in the hospital who appears to have little interest in eating. When you ask her why she doesn’t eat much, she tells you, “Ever since I started this medication, everything just tastes bland to me.” The client also complains of having a dry mouth. Which of the following conditions is most likely impairing the client’s sense of taste?

1) Anosmia
2) Presbycusis
3) Strabismus
4) Xerostomia

A

ANS - 4

When the sense of smell is lost (anosmia), food does not taste the same. However, anosmia is not associated with medication use or dry mouth.

Presbycusis is a progressive sensorineural loss associated with aging. It results from deterioration of the hair cells in the cochlea. Presbycusis leads to diminished ability to hear high-pitched sounds and to distinguish sounds in a noisy environment.

Strabismus (crossed-eyes), in which one eye deviates from a fixed image, can cause permanent vision loss.

Impaired taste most commonly results from xerostomia (excessively dry mouth), which may be caused by medications, decreased saliva production, inadequate fluid intake, poor nutrition, or poor oral hygiene.