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Fundamentals Chapter 30 - Sensation, Perception, Cognition

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1

The 5 Sensory Systems?

Vision
Hearing
Taste
Smell
Touch

2

What is the purpose of sensation?

To allow the body to respond to changing situations and maintain homeostasis.

3

The sensory experience involves what 4 components in the nervous system?

Stimulus

Reception

Perception

Arousal Mechanism

4

Components of the Sensory Experience:

Stimulus

It may be a sight, sound, taste, touch, pain, or anything that stimulates a nerve receptor. The brain must receive and process it to make it meaningful.

5

Components of the Sensory Experience:

Reception

The process of receiving stimuli from nerve endings in the skin and inside the body. A receptor converts a stimulus to a nerve impulse and transmits the impulse along sensory neurons to the central nervous system (CNS). Some receptors remain activated for as long as the stimulus is applied. However, most receptors adapt to stimuli; that is, their response declines with time. Adaptation explains why, over time, you become unaware of an unpleasant smell or the persistent hum of an air conditioner.

6

Name a few receptors in the body?

Mechanoreceptors in the skin/hair follicles detect touch pressure and vibration

Hair cells are receptors for hearing, located in cochlea

Thermoreceptors in the skin detect temperature

Proporoceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to help us sense the position of our body in space

Photoreceptors located in retina detect visible light

Chemoreceptors for taste

Olfacory receptors a type of chemoreceptor for smell

7

Components of the Sensory Experience:

Perception

The ability to interpret the impulses transmitted from the receptors and give meaning to the stimuli. The brain discards about 99% of all sensory info as irrelevant and unimportant.

8

What factors affect the perception of a stimulus?

  • location of the receptors and pathway activated
  • Number of receptors activated
  • Frequency of action potentials generated (which varies according to the intensity of the stimulus)
  • Changes in location, number, and frequency
9

Components of the Sensory Experience:

Arousal mechanism: Reticular Activating System (RAS)

Located in the brainstem, controls consciousness and alertness.

The neurons of the RAS make connections between the spinal cord, cerebellum, thalamus, and cerebral cortex, relaying visual, auditory, and other stimuli that help keep us awake, attentive, and observant. Without such stimuli, the CNS becomes lethargic, and the person may lose consciousness. Anesthesia, sedatives, opioids, and some other drugs depress the RAS, as does a darkened, quiet environment.

10

The response to a stimulus is based on what 4 factors?

  • Intensity of stimulus: An intense stimulus excites more receptors, leading to a greater response.
  • Contrasting stimuli: Contrast is also stimulating.
  • Adaption to stimuli: 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.
  • Previous experience: Prior experience with a stimulus affects ongoing responses to the same stimulus.
11

The client who has had a stroke states to the nurse, "you know I can't even tell where my left leg is." This reflects lack of response to stimuli by the:

a. Mechanoreceptors
b. Proprioceptors
c. Thermoreceptors
d. Chemoreceptors

Correct answer: B

The stimuli gathered by proprioreceptors enable us to determine the position of our bodies in space.

12

Factors Affecting Sensory Function:

Age/stage of life

People have differing sensory perceptual abilities at different stages of life.

13

Factors Affecting Sensory Function:

Culture

Affects the nature, type, and amount of interaction and stimulation that people feel comfortable with. People of different cultural backgrounds tend to prefer differing amounts of eye contact, personal space, and physical touch.

14

Factors Affecting Sensory Function:

Illness

Neurological disorders, such as multiple sclerosis, slow the transmission of nerve impulses. Diseases that affect circulation (e.g., atherosclerosis) may impair function of the sensory receptors and the brain, thereby altering perception and response. Some diseases affect specific sensory organs. For example, diabetic retinopathy is the leading cause of blindness among adults ages 20 to 74. Hypertension, too, can damage the retina of the eyes.

15

Factors Affecting Sensory Function:

Medications

Aspirin and furosemide (Lasix) become ototoxic if taken for a long period of time and impair function of the auditory nerve. CNS depressants, such as opioid analgesics and sedatives, blunt reception and perception of stimuli.

16

Factors Affecting Sensory Function:

Stress

Physical illness, pain, hospitalization, tests, and surgery are all stressors that can lead to sensory overload—more stimuli than the person can handle.

17

Factors Affecting Sensory Function:

Personality

People vary in their personalities and lifestyles. Some people, by nature, like excitement, change, and stimulation; others prefer a more predictable and quiet life. Clients are at risk for sensory alterations if their previous level of stimuli does not match their current level. Health problems, a change of environment, or loss of a partner can each create changes in stimuli.

18

What are some changes associated with vision in regards to aging?

The vitreous humor becomes thinner, and "floaters"appear in the visual field.

Peripheral vision and tear production decrease

The lens becomes less flexible and/or discolored and opaque; the pupil becomes smaller allowing less light to reach the retina limiting vision.

19

What are some changes associated with hearing in regards to aging?

Cerumen is drier and more solid creating hearing loss

Scarring occurs

Hearing changes commoly include presbycusis (hearing loss of high frequency tones) and decreased speech discrimination

20

What are some changes associated with taste in regards to aging?

Taste buds atrophy and decrease in number, so there is less ability to perceive tastes, especially sweetness. Dry mouth may also alter the taste.

21

What are some changes associated with smell in regards to aging?

Atrophy and loss of olfactory neurons decreases the ability to perceive smell, which may also alter the sense of taste.

22

What are some changes associated with touch in regards to aging?

Loss of sensory nerve fibers and changes in the cerebral cortex decrease the ability to perceive light touch, pain, and temperature variations.

23

What are some changes associated with Kinesthesia in regards to aging?

Changes include decrease in muscle fibers and diminished conduction speed of nerve fibers, resulting in slowed reaction time, decreased speed and power of muscle contractions and impaired balance.

24

Sensory Deprevation

A state of RAS depression caused by a lack of meaningful stimuli. When environmental stimuli are deficient, the remaining stimuli, such as distant noises, minor pain, and cold extremities, can become overly noticeable or distorted, filling in the “sensory gap” and causing the patient a level of distress that is out of proportion to the intensity of the stimulus.

25

Sensory Overload

Develops when either environmental or internal stimuli or a combination of both exceed a higher level than the patient's sensory system can effectively process. For example, hospitalized patients often experience sensory overload due to a combination of physical discomfort, anxiety, separation from loved ones, and the unfamiliar hospital environment.

26

The 5 signs of sensory deprivation and sensory overload that are SIMILAR

Irritability

Confusion

Reduced Attention Span

Decreased Problem Solving Ability

Drowsiness (due to insomnia for sensory overload)

27

What are 4 additional signs of sensory deprivation

Depression

Preoccupation with somatic complaints (eg, heart palpitations)

Delusions (misinterpretation of external stimuli)

Hallucinations (seeing hearing feeling tasting, or smelling something that is not there)

28

What are 6 additional signs of sensory overload?

Muscle tension

Anxiety

Inability to concentrate

Decreased ability to perform tasks

Restlessness

Disorientation

29

Sensory Deficit

May stem from impaired reception, perception or both. Of the 6 basic sensory deficits, impaired vision and hearing are the ones you're most likely to encounter in nursing practice.

30

Sensory Deficit

Impaired Vision

Visual deficits may result from trauma or disease of the eye, microvascular problems, or CNS disorders. Common causes of visual deficits include age-related changes, refractive errors, orbital trauma, cataracts, glaucoma, diabetic or hypertensive retinopathy, macular degeneration, or loss of visual fields after a stroke. Changes in vision affect all aspects of daily living and may severely limit mobility
and interaction.

31

Sensory Deficit

Impaired Hearing

Hearing deficits may result from injury or disease in structures of the ear, the nerves, or the brain. Inability to hear decreases the ability to communicate and thus hampers social interaction. It may interfere with a patient’s ability to understand instructions from healthcare professionals and create a safety hazard due to inability to hear warnings.

32

Sensory Deficit

Impaired Taste

Taste deficits may decrease the pleasure associated with eating; weight loss and malnutrition may result.

33

Xerostomia

Excessively dry mouth...may be caused by meds, decreased saliva production, inadequate fluid intake, poor nutrition, or poor oral hygiene.

34

Kinesthesia

Muscle sense, a complex process involving proprioceptors that detect stretch in muscles to create a mental picture of how the body is positioned.

Parkinson's disease and other neurological disorders (tumors, stroke, meds) can impair kinesthesia.

35

Sensory Deficit:

Impaired Tactile Sensation

Can be caused by a cerebrovascular accident (stroke), brain or spinal tumor or injury, or peripheral nerve damage caused by diabetes, Guillain-Barré syndrome, or chronic alcoholism.

36

Sensory Deficit

Impaired Smell

When the sense of smell is lost (anosmia), food does not taste the same. Patients who are unable to smell food lose their appetite, and nutritional deficits may result. Permanent anosmia may develop after cranial nerve damage, a tumor, or atherosclerosis.

37

Presbyopia

A change in vision associated with aging. The lens becomes less elastic and less able to accommodate to near objects. If you are older than 40, there's a good chance you may be experiencing this problem :-[

38

Cataracts

A clouding of the lens, resulting in blurred vision, sensitivity to glare, and image distortion.

39

Glaucoma

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. It can eventually lead to blindness.

40

Strabismus

Crossed Eyes in which one eye deviates from a fixed image, can cause permanent vision loss.

41

Conduction deafness

Hearing deficit that results when one of the structures that transmits vibrations is affected. It may be a temporary or permanent condition caused by infection of the middle ear, a punctured tympanic membrane, or arthritis of the auditory bones. A hearing aid may be helpful.

42

Presbycusis

Hearing deficit that is a progressive sensorineural loss associated with aging. It results from deterioration of the hair cells in the cochlea. Leads to diminished ability to hear high pitched sounds and to distinguish sounds in a noisy environment. Hearing aids may be of no value.

43

Tinnitus

Hearing deficit that describes ringing in the ears. It mostly comes from damage to the microscopic endings of the nerve in the inner ear, for ex, trauma, turbulent blood flow, hypertension, ear infection, meds, otosclerosis, or arthritic changes of the bones of the ear.

44

Otitis Media

A middle ear infection. It is a common childhood illness that may be caused by viruses or bacteria.

45

Assessment of sensory perception includes a history and physical exam to gather data about?

  • Factors affecting sensory perception
  • Mental status, mood, affect, cognition, and memory
  • Level of consciousness (LOC)
  • Use of sensory aids
  • The patient's environment
  • The support network
  • Focused exam of vision, hearing, taste, smell, touch, balance, ability to respond to stimulation, muscle tone, coordination
46

Nursing Diagnosis

Acute Confusion

Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time.

47

Nursing Diagnosis

Chronic Confusion

Irreversible, long-standing, and or progressive deterioration of intellect and personality characterized by a decreased ability to interpret environmental stimuli and decreased capacity for intellectual thought processes and manifested by disturbances of memory orientation, and behavior

48

Nursing Diagnosis

Impaired Memory

Inability to remember or recall bits of information or behavioral skills

49

Nursing Diagnosis

Risk for Falls

Vulnerable to increased susceptibility to falling, which may cause physical harm and compromise health.

50

What are some nursing interventions for sensory deprivation?

Orientation: provide a calendar or a view of the environment

Provide stimuli: regular contact, touch, television, radio, pet therapy, smells

51

What are some nursing interventions for sensory overload?

Minimize the stimuli: less light or noise, less TV or radio, calm tone, reduce noxious odors, provide rest and teach stress reduction.

52

Mr. Arbor complains to the nurse that he is feeling anxious. He states, “I’m just so tired of all these tests they are doing, and it’s so noisy here at night.” Mr. Arbor’s pulse is 110 beats/min, and his blood pressure is 140/70 mm Hg. Nursing actions should include which of the following?

a.Turn on the television to provide distraction.

b.Ask the client if he would like to discuss his anxiety further.

c.Close the blinds, dim the lights, and ask the patient what other measures would help him rest.

d.Call the physician and obtain an order for an anti-anxiety medication for prn use.

Correct answer: C

These measures would most directly decrease the client’s sensory overload.

53

What are some nursing interventions for impaired vision?

Supply clean glasses, sufficient light, protect eyes from sunlight, provide a magnifying lens or large print books.

Evaluate their ability to perform ADLS, remain safe in environment, and need for assistance

54

What are some nursing interventions for impaired hearing?

Care of hearing aid, use closed captioned TV, Regular inspection of ear canal, teach techniques to improve communication, promote safety and assess for social isolation

55

What are some nursing interventions for the confused patient?

Reorient frequently, state your name, day, date, time, provide clocks, calendars, visual clues to time, use personal belongings, maintain a safe environment, communicate clearly and slowly, limit choices, promote feeling of security, and use alternative therapies.

56

What are some nsg interventions for the unconscious pt?

Continue to orient to reality

Safety measures: bed in low position and side rails up

Attend to body systems: eye care, ROM, skin and mouth care, urinary drainage, bowel management, nutrition

57

Possible Bonus Question:

Essential Oils-How are they thought to work?

By promoting the body's natural ability to balance, regulate, heal, and maintain itself.

58

Possible Bonus Question:

Lavender, Lavandula angustifolia used for?

Relaxing
Treating wounds and burns
Skin Care
Asthma
Itching
Labor Pains
Colic
Dysmenorrhea

59

Possible Bonus Question:

Peppermint, Mentha piperita used for?

Headaches
Sinusitis
Vertigo
Muscle Aches
Asthma
Digestive Disorders: slow digestion, indigestion, nausea and gas

60

Possible Bonus Question:

Rosemary, Rosmarinus officinalis

Promotes mental stimulation
Stimulates immune, circulatory, and digestive systems, muscle aches and tension

61

Possible Bonus Question:

Tea Tree, Melaleuca alternifolia

Antifungal oil: yeast infection, jock itch, athletes foot, and ringworm.

Insect bites, itching, migrane

boosts immune system

62

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

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.

63

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)

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.

64

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

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.

65

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

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.

66

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

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.

67

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.

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.

68

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

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.

69

A patient with Parkinson's disease is at risk for which complication?
1) Impaired kinesthesia
2) Macular degeneration
3) Seizures
4) Xerostomia

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.

70

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

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.

71

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

1

Correct!

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.

72

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

4

Correct!

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.

73

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) Chemoreceptor

1

Correct!

Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

74

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.

1,4,5

Correct!

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.

75

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

3,4,5

Correct!

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.

76

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

2

Correct!

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.

77

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

3

Correct!

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.

78

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

3

Correct!

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.

79

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

1

Correct!

Some diseases affect specific sensory organs. For example, diabetic retinopathy is the leading cause of blindness among adults aged 20 to 74 years.

80

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

2,4,5

Correct!

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.

81

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

1,2,4,6

Correct!

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.

82

Below are the steps for performing an otic irrigation on an adult client. Put them in the correct order.

  • Straighten the ear canal by pulling up and back on the pinna.
  • Continue irrigating until the canal is clean.
  • Warm the irrigating solution to body temperature.
  • Instruct the patient to notify you if he experiences any pain or dizziness during the irrigation.
  • Assist the patient into a sitting or lying position, with the head tilted slightly toward the affected ear.
  • Place the tip of the nozzle (or syringe) into the entrance of the ear canal, and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the client's head.
  • Perform an otoscopic examination.
  • Place a cotton ball loosely in the outer ear.

Correct!

The steps for performing otic irrigation on an adult client are as follows: 1. Warm the irrigating solution to body temperature. 2. Assist the patient into a sitting or lying position, with the head tilted slightly toward the affected ear. 3. Straighten the ear canal by pulling up and back on the pinna. 4. Instruct the patient to notify you if he experiences any pain or dizziness during the irrigation. 5. Place the tip of the nozzle (or syringe) into the entrance of the ear canal, and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the client's head. 6. Continue irrigating until the canal is clean. 7. Perform an otoscopic examination. 8. Place a cotton ball loosely in the outer ear.

83

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.

3

Correct!

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

84

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.

1,2,4

Correct!

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.

85

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

3

Correct!

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).


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