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Sensation, perception, and cognition > Fundamentals
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Showing 15 questions, Sign in for moreWhen planning the care for a patient related to disturbed sensory perception, the nurse would integrate knowledge of which system as responsible for monitoring and regulating incoming sensory stimuli to maintain, enhance, or inhibit cortical arousal?
You notice that Mr. Wong, who has cataracts, is sitting closer to the television than usual. The nurse would interpret the etiologic basis of his sensory problem is an alteration in which of the following?
Peter Almone is in the late stages of AIDS, which is now affecting his brain as well other major organ systems. He confides to you that he feels terribly alone because most of his friends are afraid to visit. The nurse determines that which of the following would be the least likely underlying etiology for his sensory problems?
Which factor is least likely to place a patient at high risk for sensory deprivation?
Which patient would the nurse assess as being at greatest risk for sensory deprivation?
A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 6, 7, and 8 PM. A heart monitor beeps for a patient on one side, and another patient moans frequently. Assessment would suggest that that the patient probably is experiencing which of the following?
Richard’s spinal cord was severed, and he is paralyzed from the waist down. When obtaining data about this patient, which component of the sensory experience would be most important to assess?
An 11-year-old 6th grader whose grades have dropped has difficulty completing her work on time, frequently rubs her eyes, and squints. Her visual acuity on a Snellen’s eye chart was 160/20. Which nursing diagnosis would be most appropriate?
Of the four items listed below, which nursing intervention would be best to prevent sensory alterations for a man with a severe hearing deficit who reads lips well?
The nursing diagnosis for 8-month-old Sally was Disturbed Sensory Perception: Sensory Deprivation related to inadequate parenting. Since that time, both parents have attended parenting classes. However, both parents work while Sally stays with her 86-year-old grandmother, who has reduced vision. The parents provide appropriate stimulation in the evening. At an evaluation conference at age 11 months, Sally lays on the floor sucking her thumb and rocking her body. Her facial expression is dull, and she vocalizes only in a low monotone (“uh-h-h”). Which statement accurately reflects evaluation about the child’s sensory deprivation?
Which nursing interventions would be least appropriate for an elderly woman in a nursing home with a nursing diagnosis of Disturbed Sensory Perception: Chronic Sensory Deprivation related to the effects of aging? She had walked out the door unobserved and was hit by a car.
A new nurse is going to help a patient walk down the corridor and sit in a chair. The patient has an eye patch over the left eye and poor vision in the right eye. What is the correct order of steps to help the patient safely walk down the hall and sit in the chair?
Explanation
To ensure safe ambulation techniques for visually impaired clients, nurses must use guiding methods that prioritize safety, independence, and dignity, such as offering the arm, walking slightly ahead, and providing clear verbal and tactile cues.
Rationale for correct answer:
3. Guide the patient’s hand to your arm, resting just above the elbow: This is the standard guiding technique for visually impaired clients. It provides stability and allows the nurse to lead safely.
4. Position yourself one-half step in front of the patient: Being slightly ahead enables the nurse to lead while the patient follows smoothly, sensing movement changes.
2. Walk at a relaxed pace: A steady, relaxed pace ensures safety and allows the patient to follow naturally without rushing.
1. Tell the patient when you are approaching the chair: The patient needs orientation before attempting to sit. Giving this cue prepares them mentally and physically.
5. Position the patient’s hand on the back of the chair: This gives the patient tactile orientation to the chair and promotes independence and safety when sitting down.
Take home points
- Always use guiding techniques: Offer your arm, walk slightly ahead, and give verbal/tactile cues.
- Promote independence and orientation: Help the client feel the chair so they can sit safely on their own.
A patient with progressive vision impairments had to surrender his driver’s license 6 months ago. He comes to the medical clinic for a routine checkup. He is accompanied by his son. His wife died 2 years ago, and he admits to feeling lonely much of the time. Which of the following interventions reduce loneliness? Select all that apply
A nurse is performing an assessment on a patient admitted to the unit following treatment in the emergency department for severe bilateral eye trauma. During patient admission the nurse’s priority interventions include which of the following? Select all that apply
A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, “I think my hearing aid is broken. I can’t hear anything.” After determining that the patient’s hearing aid works and that the patient is having trouble managing the hearing aid at home, which of the following teaching strategies does the nurse implement? Select all that apply
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