Practice Exercise 1

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Total Questions : 5

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Question 1:

Which client is at greatest risk for experiencing sensory overload?

Answer and Explanation

A
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Question 2:

A client is at risk for sensory deprivation. Which of the following clinical signs would the nurse observe? Select all that apply

Answer and Explanation

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Question 3:

The nurse is assessing for sensory function. Match the assessment tool to the specific sense it will be testing.

 

 

 

Identifying taste

Stereognosis

Snellen chart

Identifying aromas

Tuning fork

Answer and Explanation

Explanation

This question is assessing the nurse’s knowledge of neurological and sensory function assessments. Each tool or activity is designed to evaluate a specific sensory pathway- vision, hearing, tactile perception, olfaction, or taste - which is essential for detecting deficits and planning interventions.

Rationale for correct answer:

Identifying taste → Gustatory (5): The gustatory sense involves taste perception. Asking a client to identify flavors such as sweet, salty, or sour tests cranial nerves VII (facial) and IX (glossopharyngeal).

Stereognosis → Tactile (3): Stereognosis is the ability to identify an object placed in the hand (like a key or coin) without visual input. This assesses tactile sensation and cortical integration.

Snellen chart → Visual (1): The Snellen chart measures visual acuity by having clients read letters at a distance, assessing cranial nerve II (optic nerve).

Identifying aromas → Olfactory (4): Asking the client to recognize smells such as coffee or peppermint evaluates the olfactory sense, which tests cranial nerve I (olfactory nerve).

Tuning fork → Hearing (2): A tuning fork is used for auditory assessments such as the Rinne or Weber test, which evaluate air and bone conduction and test cranial nerve VIII (vestibulocochlear).

Take-home points:

  • Each sensory assessment is linked to a specific cranial nerve and pathway, making accurate tool selection essential for neurological exams.
  • Nurses should know how to differentiate sensory modalities (visual, hearing, tactile, olfactory, gustatory) to detect deficits early and intervene appropriately.

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Question 4:

When assessing a patient’s sensory experience, which of the following would the nurse identify as the major components?

Answer and Explanation

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Question 5:

When evaluating a patient’s sensory experience, which four conditions would be essential for a person to receive data and experience the world?

Answer and Explanation

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