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Exam 39: Sensory Perception

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Question 1

Multiple Choice

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Which assessment findings would the nurse interpret as being possible signs of sensory overload in a hospitalised client?

A) Sleeplessness.
B) Anxiety.
C) Apathy.
D) Racing thoughts.
E) Somatic complaints.

Correct Answer

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A,B,D

Question 2

Multiple Choice

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The client has a long history of congestive heart failure and has been treated with large amounts of intravenous frusemide (Lasix) . Based upon this history, for which sensory impairment would the nurse monitor this client?

A) Loss of ability to taste.
B) Vision loss.
C) Hearing loss.
D) Loss of ability to smell.

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Question 3

Multiple Choice

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The nurse is providing education for the parents of a newborn. What advice should the nurse provide in respect to hearing loss screening?

Sensoristasis is a term used to describe when a person:

An older client has become very confused since being hospitalised earlier in the week. Prior to this illness, the client exhibited clear thought processing and was able to maintain an independent lifestyle. How would the nurse document this mental state?

Match the following terms with its relevant description.

The nurse is assessing a client who was just brought to the emergency department. The client can be aroused only with extreme or repeated stimuli. How should the nurse describe this client in a report to the ED physician?

The client who has the medical diagnosis of Alzheimer's disease is confused and has difficulty interpreting environmental stimuli. Which nursing diagnosis problem statement most accurately describes this client's situation?

The nurse is planning care for a client who is experiencing dementia. What essential concept should the nurse consider for this planning?

The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this intervention?

The client has had a cerebral vascular accident (CVA) and now cannot speak. It is unclear from assessment if the client understands spoken words. What NANDA-I nursing diagnosis problem statement would be used for this client?

During review of admission data, the nurse learns that the new client has impairment of kinaesthetic sensation. Which nursing intervention should be planned for this client?

The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse implement?

A new client has recently undergone a series of extensive tests for cancer and undergone major surgery. The nurse notices that the client is restless, irritable and having difficulty undertaking activities of daily living. The client is experiencing:

Which recent change, reported by a client's family, would indicate that the client's hearing ability is decreasing?

A nurse is visiting an elderly client who lives at home alone and has no family supports. The nurse observes that the client is becoming increasingly depressed and focused on her health problems. The nurse encourages the client to:

Which of the following clients would be at a higher risk of sensory deprivation?

A nurse working in a nursing home is caring for a client with acute delirium. Which of the following would not be an appropriate strategy to maintain the client's orientation?

A hospitalised elderly man suddenly does not recognise his daughter and complains that his wife has not visited him, even though she has been dead for five years. The client was clear of mind and thought prior to hospitalisation. What NANDA-I nursing diagnosis problem statement would be used for this client?

The client is being treated in an intensive care unit for a complicated myocardial infarction. The client's family lives 250 kilometres away and is unable to visit. Is this client at greater risk for sensory overload or sensory deprivation?