chapter 45 sensory functioning

A client who is blind is said to be experiencing:

sensory deficit.

For which conditions would the nurse assess a client to determine the ability to adequately receive the data necessary to experience the world? Select all that apply.

• a stimulus

• a receptor or sense organ

• an intact nerve pathway

• a functioning brain

A community health nurse is conducting a seminar on vision self-care. Which actions will the nurse recommend to prevent UV damage? Select all that apply.

• Check that your sunglasses block 100% of UV light.

• Remember to wear sunglasses even when in the shade.

• Wear sunglasses in summer and winter.

• Even if contact lenses block UV rays, you still need to wear sunglasses.

• If you have dark skin and eyes, you still need to wear sunglasses.

The nurse is teaching a group of clients about general eye care to prevent vision loss and eye injury. What will the nurse include in the presentation? Select all that apply.

• Avoid eye damage from ultraviolet rays.

• Use caution with corrosive agents.

• Avoid eye strain and rubbing eyes.

• Wear protective goggles for mowing lawns.

A client has just been told that they have lung cancer. The health care provider then describes several potential courses of treatment to the client. When the health care provider leaves the room, the client asks the nurse, "What did the health care provider just say?" The nurse understands that the client is experiencing:

sensory overload.

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

perception.

A nurse who provides care in a long-term setting is aware of the need to promote and protect sensory stimulation for residents. What interventions should the nurse choose in order to achieve this goal? Select all that apply.

• Regularly assess residents for age-related sensory losses.

• Regularly reorient residents who are disoriented to person, place, or time.

• Ensure that residents who require assistive devices are regularly using them.

• Assess residents for the CNS effects of drugs and the potential for polypharmacy.

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls?

Monitor the client frequently.

The health care provider tells the nurse that the older adult client has presbycusis. Which intervention will the nurse place in the client's care plan?

Decrease background noise as much as possible before speaking.

Sensory function begins with the reception of stimuli by the senses. Which are special senses? Select all that apply.

• visual

• gustatory

• auditory

The nurse is caring for an older hospitalized client who has no local support network and who has been placed on isolation due to neutropenia. How should the nurse best attend to the client's sensory needs?

Engage with the client meaningfully several times daily.

A client informs the nurse that they are not able to recall their phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory

A client is able to sleep through near-constant elevated train noise near their home but is roused when their child walks around the apartment. What does the nurse identify is occurring with the client?

reticular activating system's selective stimulation

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which question will the nurse ask?

"Do you work around loud noises at work?"

A nurse is assessing a client's state of awareness and finds the client to be disoriented and restless. The client is also agitated and alternates from confusion to excessive drowsiness to extreme excitability. The nurse would document this as:

delirium.

A client who was admitted to the critical care unit is experiencing sensory overload. When developing this client's plan of care, which intervention would be appropriate for the nurse to include? Select all that apply.

• Offer simple explanations before a treatment or procedure.

• Set up a consistent schedule for routine care activities.

• Suggest the use of noise-reducing headphones or ear plugs.

The nurse is caring for a client at risk for the development of cognitive impairment related to a spinal cord injury. When creating the plan of care for this client, what interventions should the nurse include to avoid this development? Select all that apply.

• Discuss current events or the client's occupation, hobbies, or interests.

• Have the client assist in self-care as much as possible.

• Orient the client to the surroundings and environment every 1 to 2 hours.

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and believing to be in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time.

An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned.” Which is the best way for the nurse to address the client’s statement?

“What makes you think the food is poisoned?”

A nurse in the emergency room is assessing a client for sensory perception dysfunction. Which assessment techniques will the nurse use to gather objective data? Select all that apply.

• observation

• physical assessment

• diagnostic tests and procedures

The nurse will be starting an intravenous line on a client with limited hearing. The nurse will implement which intervention(s)? Select all that apply

• Ask, “May I turn down the sound on your television?”

• Speak directly to the client.

• Look at the client’s face as much as practical.

The nurse is preparing a care plan for a client with disturbed sensory perception related to overstimulation. What would be an appropriate goal(s) for the client to achieve? Select all that apply.

• The client will state feeling rested after sleeping.

• The client will not fall during the hospital stay.

• The client will develop effective communication during the hospital stay.

The cardiac monitor technician is installing new monitors. The intensive care unit (ICU) nurse asks that the monitors have different sound levels for the more lethal alarms as the repeated stimulus of a continuing noise often goes unnoticed. The ICU nurse explains that this phenomenon is known as:

adaptation.

Which situation demonstrates sensory adaptation?

A client has learned to sleep through the frequent beeping of the intravenous pump.

A client who is experiencing sensory deprivation may benefit from the use of good working sensory aids. What sensory aids can the nurse implement to prevent the occurrence of sensory deprivation in this client? Select all that apply.

• make sure the client has working hearing aids with fresh batteries

• clean prescription glasses

• schedule activities for the day

• assess the fit of dentures

A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as well as techniques to follow when working with clients with limited hearing. Which nursing intervention is appropriate?

demonstrating or pantomiming ideas

The nurse is caring for an 81-year-old client who is struggling to adapt to worsening vision as they age. The nurse performs which interventions to assist the client in adapting to this sensory deficit? Choose all that apply.

• Make sure their glasses are available.

• Provide adequate lighting.

• Provide large print books.

A client who hallucinates simply to maintain an optimal level of arousal is experiencing:

sensory deprivation.

The nurse is creating a care plan for the legally blind client who is confused and easily agitated. Which priority outcome is appropriate for this client?

The client will remain safe.

Which nursing action(s) aligns with best practices when caring for clients with limited vision? Select all that apply.

• Speak in a normal tone of voice.

• Orient the person to the arrangement of the room and its furnishings.

• Sit in the person’s field of vision if they have partial or reduced peripheral vision.

The nurse is caring for a hospitalized 90-year-old client. What will the nurse include in the care plan?

decreasing environmental noise

A 4-year-old child's parent is employed and works from home. To accomplish their daily work, the parent allows the child to watch television for 6 to 8 hours per day. Based on this information, what nursing concern is applicable to this family?

altered parenting associated with failure to provide stimuli for growth

The nurse is conducting health education with a group of older adults in the clinic. Which activity should the nurse include in the education that can prevent sensory loss in the older adult population?

good management of illness such as hypertension

Which is not a lifespan consideration for sensory perception?

A newborn's sensory perception is very refined.

A cycling accident has resulted in a head injury to a client with resultant increased intracranial pressure. Consequently, the client has been placed in a private room with low light and care has been organized to minimize disturbances. What situation is the client most likely at risk for?

Sensory Deprivation

An intensive care unit (ICU) has taken action to eliminate unnecessary noises and lights on the unit. What is the likely outcome of this initiative?

Clients will experience decreased levels of anxiety and irritability.

The nurse is caring for an 88-year-old resident of a nursing home who is experiencing sensory deprivation. The resident lives in a small room, has no visitors, and has few interests. The nurse performs which intervention(s) to assist the resident in adapting to this sensory deficit? Select all that apply.

• Provide interactions with children and pets.

• Encourage the resident to attend exercise classes.

• Ensure that the resident eats at a table with other residents.

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

• Depression

• Sleeplessness

• Decreased interest in activities

The nurse is planning strategies to increase sensory stimulation for clients in isolation. Which consideration(s) should the nurse keep in mind to provide trauma-informed, person-centered care? Select all that apply.

• Sensory functioning tends to decline progressively throughout adulthood.

• An individual’s culture may dictate the amount of sensory stimulation considered normal.

• Different personality types demand different levels of stimulation.

A client with chronic sinusitis reports loss of appetite. Which action(s) will the nurse recommend to the client to help overcome this issue? Select all that apply.

• Imagine the smell of the food while eating

• Contact your health care provider

• Research smell training

• Enhance the flavor of the food you eat.

• Carefully review expiration dates on food.

The nurse is caring for a client with sensory perception deficits. Which sensory aids can the nurse use for this client to adjust to these deficits? Select all that apply.

• literature with large print

• speaking slowly

• fresh food served for meals

• turning and repositioning

• sips of water between foods

After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment?

having a caregiver in the home for the first few days after surgery

For which client will the nurse provide interventions aimed at preventing sensory overload?

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

The nurse is working on a neurological unit and a health care provider asks the nurse to perform a sensory experience assessment for a client. The nurse thinks about what things may place a person at risk for disturbed sensory perception and comes up with which of the following? Select all that apply.

• diminished senses related to advanced age

• neuropathy related to diabetes mellitus

• medications that alter certain senses

A nurse in the emergency room is assessing a client for sensory perception dysfunction. Which assessment techniques will the nurse use to gather objective data? Select all that apply.

• observation

• physical assessment

• diagnostic tests and procedures

A client has expressed great relief at the improvement in their hearing after irrigation of the ear canal yielded a large amount of impacted cerumen. This client was experiencing a sensory alteration related to:

sensory reception.

A nurse is assessing clients in a burn unit for sensory alterations. Which factors contribute to severe sensory alterations? Select all that apply.

• Sensory overload

• Sensory deprivation

• Sleep deprivation

A neonatal intensive care nurse is caring for an infant born prematurely. How will the nurse manage the infant's environment to best support their sensory needs?

Limit lighting, visual, and vestibular stimulation.

The student is explaining the factors affecting sensory stimulation to the professor. Which student statement is accurate?

"Religious norms within a culture influence the amount of sensory stimulation a person seeks."

A nurse is caring for a 13-year-old client who has suffered a concussion while playing hockey. The morning assessment finds them very drowsy but they respond normally to stimuli. What does the nurse document as the client's level of consciousness?

Somnolence