Chapter 29. Sensory Perception My Nursing Test Banks

Chapter 29. Sensory Perception

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. The nurse checks a patients pupils using a penlight. Which receptors is the nurse stimulating?

1)

Chemoreceptors

2)

Photoreceptors

3)

Proprioceptors

4)

Mechanoreceptors

____ 2. Which structure within the brain is responsible for consciousness and alertness?

1)

Reticular activating system

2)

Cerebellum

3)

Thalamus

4)

Hypothalamus

____ 3. The nurse has been teaching a parent about stimuli to develop her infants auditory nervous system. Which behavior by a parent toward the child provides evidence that learning occurred?

1)

Cuddling

2)

Speaking

3)

Feeding

4)

Soothing

____ 4. A patient complains to the nurse that since taking a medication he has suffered from excessively dry mouth. What term should the nurse use to document this complaint?

1)

Exophthalmos

2)

Anosomia

3)

Insomnia

4)

Xerostomia

____ 5. Which nursing diagnosis has the highest priority for a patient with impaired tactile perception?

1)

Self-Care Deficit: Dressing and Grooming

2)

Impaired Adjustment

3)

Risk for Injury

4)

Activity Intolerance

____ 6. A patient with Parkinsons disease is at risk for which complication?

1)

Impaired kinesthesia

2)

Macular degeneration

3)

Seizures

4)

Xerostomia

____ 7. The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient?

1)

Encouraging family members to visit only during the day

2)

Applying wrist restraints during periods of agitation

3)

Playing soft, calming music during the evening

4)

Administering lorazepam (a tranquilizer)

____ 8. Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory?

1)

Limit oral hygiene to one time a day.

2)

Teach the patient to combine foods in each bite.

3)

Assess for sores or open areas in the mouth.

4)

Instruct the patient to avoid salt substitutes.

____ 9. A patient diagnosed with macular degeneration asks the nurse to explain his condition. Which statement by the nurse best describes macular degeneration?

1)

The portion of your eye called the macula, which is responsible for central vision, is damaged.

2)

Your lens became cloudy, causing your blurred vision. This cloudiness will increase over time.

3)

The pressure in the anterior cavity of your eye became elevated, shifting the position of your lens.

4)

Theres an irregular curvature of your cornea, causing your blurred vision.

____ 10. A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss?

1)

Otosclerosis

2)

Conduction deafness

3)

Presbycusis

4)

Central deafness

____ 11. A patient comes to the clinic complaining of a taste disturbance. Which medication that the patient is currently prescribed is most likely responsible for this disturbance?

1)

Furosemide, a diuretic

2)

Phenytoin, an anticonvulsant

3)

Glyburide, an antidiabetic

4)

Heparin, an anticoagulant

____ 12. Which instruction should the nurse be certain to include when providing discharge teaching for a patient who has a serious visual deficit?

1)

Install blinking lights to alert an incoming phone call.

2)

Have gas appliances inspected regularly to detect gas leaks.

3)

Wear properly fitting shoes and socks.

4)

Avoid using throw rugs on the floors.

____ 13. The nurse must irrigate the ear of a 4-year-old child. How should the nurse pull the pinna to straighten the childs ear canal?

1)

Up and back

2)

Straight back

3)

Down and back

4)

Straight upward

____ 14. Which step should the nurse take first when performing otic irrigation in an adult?

1)

Warm the irrigation solution to room temperature.

2)

Position the patient so she is sitting with her head tilted away from the affected ear.

3)

Straighten the ear canal by pulling up and back on the pinna.

4)

Place the tip of the nozzle into the entrance of the ear canal.

____ 15. Which essential oil might the nurse trained in aromatherapy use to uplift and stimulate a patient?

1)

Lavender

2)

Roman chamomile

3)

Rosemary

4)

Ylang-ylang

____ 16. Which assessment finding is considered an age-related change?

1)

Presbycusis

2)

Hyperopia

3)

Increased sensitivity to touch

4)

Increased sensitivity to taste

____ 17. After sustaining a stroke, the patient lacks attention to the right side of his body. Which nursing diagnosis is best describes the patients problem?

1)

Disturbed Sensory Perception

2)

Unilateral Neglect

3)

Risk for Peripheral Vascular Dysfunction

4)

Acute Confusion

____ 18. A patient is admitted with an exacerbation of asthma. Which factor places the patient at highest risk for sensory overload?

1)

Administering albuterol (a central nervous stimulate) every as needed

2)

Administering a tranquilizer intravenously every 2 hours as prescribed

3)

Delivering oxygen at 6 L/min via nasal cannula

4)

Maintaining complete bed rest in a quiet, dimly lit room

____ 19. A patient complains of an impaired sense of smell. Which cranial nerve might have been affected?

1)

Trigeminal

2)

Glossopharyngeal

3)

Olfactory

4)

Vagus

____ 20. Which intervention is helpful when caring for a patient with impaired vision?

1)

Suggest the patient use bright overhead lighting.

2)

Advise the patient to avoid wearing sunglasses when outdoors.

3)

Do not offer large-print books, as this may embarrass the patient.

4)

Place the patients eyeglasses within easy reach.

____ 21. A patient tells the nurse that since taking a medication he has suffered from excessively dry mouth. Which of the following assessments would be needed in order to plan interventions for that symptom?

1)

Asking the patient if foods taste different now

2)

Checking the patients sense of smell

3)

Having the patient stand to check for balance

4)

Assessing for a history of seizures

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. For a particular patient, it has become essential to minimize the risk of further damage to the auditory nerve. Which of the following medications may need to be discontinued if the patient is taking them? Choose all that are correct.

1)

Furosemide, a diuretic

2)

Digoxin, a cardiotonic

3)

Famotidine, an antiacid

4)

Aspirin, an analgesic

____ 2. Which factors in a health history place a patient at risk for hearing loss? Choose all that apply.

1)

Being an older adult

2)

Childhood chickenpox

3)

Frequent otitis media

4)

Diabetes mellitus

____ 3. The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings(s) has/have aroused her suspicion? Choose all that apply.

1)

Disorientation

2)

Restlessness

3)

Hallucinations

4)

Depression

____ 4. Which action(s) can the nurse take to prevent sensory overload? Choose all that apply.

1)

Leave the television on to block out other noises.

2)

Minimize unnecessary light in the patients room.

3)

Plan care to provide uninterrupted periods of sleep.

4)

Speak calmly with a moderate voice volume.

____ 5. For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Choose all that apply.

1)

Talk to the patient as you provide care.

2)

Incorporate more touch in the plan of care.

3)

Give frequent eye care if blink reflex is absent.

4)

Keep the side rails up and bed in low position.

Chapter 29. Sensory Perception

Answer Section

MULTIPLE CHOICE

1. ANS: 2

Photoreceptors located in the retina of the eyes detect visible light. 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. 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. Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

PTS: 1 DIF: Easy REF: V1, p. 707

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

2. ANS: 1

The reticular activating system, located in the brainstem, controls consciousness and alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus controls body temperature.

PTS: 1 DIF: Easy REF: V1, p. 707

KEY: Client need: HPM | Cognitive level: Recall

3. ANS: 2

Exposure to voices, music, and ambient sound helps develop the infants auditory nervous system. Cuddling, feeding, and soothing provide comfort and pleasure and teach the infant about his external environment.

PTS: 1 DIF: Easy REF: V1, p. 709

KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Recall

4. ANS: 4

The nurse should document excessively dry mouth as xerostomia. Exophthalmos is abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosomia is losing the sense of smell. Insomnia is inability to sleep.

PTS: 1 DIF: Moderate REF: V1, p. 713

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

5. ANS: 3

The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Self-Care Deficit, Impaired Adjustment, and Activity Intolerance are also likely to be appropriate for this patient, but are not as high a priority as Risk for Injury. Risk for Injury is directly related to safety, which must always be a priority.

PTS: 1 DIF: Moderate REF: V1, p. 714 | V2, p. 699

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

6. ANS: 1

Patients with Parkinsons disease are at risk for impaired kinesthesia, placing them at risk for falling. Drooling, not excessive dry mouth (xerostomia), is common with Parkinsons disease. Seizures and macular degeneration are not associated with Parkinsons disease.

PTS: 1 DIF: Moderate REF: V1, pp. 714-715

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

7. ANS: 3

Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family member to sit with the patient might have a calming effect, but the option does not provide for that during the evening when the patient is symptomatic. Applying bilateral wrist restraints might further agitate the patient. Lorazepam will provide sedation but might cause further confusion.

PTS: 1 DIF: Moderate REF: V1, pp. 723-724

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

8. ANS: 3

The nurse should assess for sores or open areas in the mouth and provide frequent oral hygiene. The nurse should also teach the patient to eat foods separately to allow the taste of food to be distinguishable. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods, so the patient should not avoid them.

PTS: 1 DIF: Moderate REF: V1, p. 723

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

9. ANS: 1

Macular damage (degeneration) causes diminished central vision. Cataracts are caused by a cloudy lens and result in blurred vision. Glaucoma is pressure in the anterior cavity of the eye, which shifts the lens position. Astigmatism is irregular curvature of the cornea, resulting in blurred vision.

PTS: 1 DIF: Difficult REF: V1, p. 712

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

10. ANS: 4

Central deafness results from damage to the auditory areas in the temporal lobes. Otosclerosis is hardening of the bones of the middle ear, especially the stapes. Conduction deafness results when one of the structures that transmits vibrations is affected. Presbycusis is a progressive sensorineural loss associated with aging.

PTS: 1 DIF: Moderate REF: V1, p. 712

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Application

11. ANS: 2

Phenytoin is a medication that has a high incidence of associated taste disturbance. Furosemide, glyburide, and heparin are not implicated in taste disturbances.

PTS: 1 DIF: Moderate REF: V1, p. 713

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Application

12. ANS: 4

The nurse should instruct the visually impaired patient to avoid using throw rugs on the floors at home. She should instruct the patient with a hearing deficit to install blinking lights to alert him to an incoming phone call. She should instruct the patient with an olfactory deficit to have gas appliances inspected regularly to detect leaks. The patient with a tactile deficit should be instructed to use properly fitting shoes and socks.

PTS: 1 DIF: Moderate REF: V1, p. 722

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

13. ANS: 3

The nurse should straighten the ear canal of a small child by pulling the pinna down and back. To straighten the ear canal of an adult, the nurse should pull the pinna up and outward.

PTS: 1 DIF: Easy REF: V2, p. 689

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall

14. ANS: 1

The nurse should warm the irrigation solution to room temperature first. Next, the nurse should assist the patient into a sitting position, with the head tilted away from the affected ear; straighten the ear canal by pulling up and back on the pinna; place the tip of the nozzle 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 patients head. Then continue irrigating until the canal is clean.

PTS: 1 DIF: Moderate REF: V1, p. 722 | V2, p. 688

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Analysis

15. ANS: 3

Rosemary is very stimulating and uplifting. Lavender, Roman chamomile, and Ylang-ylang are used to promote relaxation.

PTS: 1 DIF: Difficult REF: V1, p. 714

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

16. ANS: 1

Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the ability to see distant objects well; it is not an age-related change. The ability to perceive touch and taste diminishes with age; it does not increase.

PTS: 1 DIF: Moderate REF: V1, p. 712

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

17. ANS: 2

This patient lacks attention to the right side of his body after sustaining a stroke; therefore, the most appropriate nursing diagnosis is Unilateral Neglect. The patient may also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and Acute Confusion, but they are not the most appropriate for the defined problem.

PTS: 1 DIF: Moderate REF: V2, p. 695

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

18. ANS: 1

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 patients 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.

PTS: 1 DIF: Difficult REF: V1, p. 711

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

19. ANS: 3

The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell. The trigeminal nerve transmits stimuli from the face and head. The glossopharyngeal nerve is responsible for taste. The vagus nerve is responsible for sensations of the throat, larynx, and thoracic and abdominal viscera.

PTS: 1 DIF: Difficult REF: V1, p. 707 | V1, p. 713

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

20. ANS: 4

The nurse should place the patients eyeglasses within easy reach and make sure that they are clean and in good repair. The patient should have sufficient light but avoid bright light, which might cause glare. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. A magnifying lens or large print books may be helpful.

PTS: 1 DIF: Moderate REF: V1, p. 721

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

21. ANS: 1

Many medications cause xerostomia (dry mouth), and xerostomia is the most common cause of impaired taste. Impaired sense of smell also affects the sense of taste; however, there is no reason to assume impaired smell in this patient. Balance is related the inner ear and to kinesthetic sense, not to taste and xerostomia. Xerostomia would be related to seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even if this were the case, the information would allow the nurse to plan care for seizures, but not for the symptom of dry mouth.

PTS: 1 DIF: Difficult REF: V1, p. 713

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

MULTIPLE RESPONSE

1. ANS: 1, 4

Aspirin and furosemide may cause ototoxicity, leading to auditory nerve impairment. Digoxin and famotidine do not place the patient at risk for auditory nerve impairment.

PTS: 1 DIF: Difficult REF: V1, p. 710

KEY: Nursing process: Assessment | Client need: SECE | Cognitive level: Comprehension

2. ANS: 1, 3

Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. Chickenpox and diabetes mellitus do not place the patient at risk for hearing loss.

PTS: 1 DIF: Moderate REF: V1, p. 709 | V1, p. 712

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

3. ANS: 1, 2

The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased ability to perform tasks, anxiety, muscle tension, and muscle tension. Sensory deprivation causes irritability, confusion, depression, heart palpitations, hallucinations, and delusions.

PTS: 1 DIF: Moderate REF: V1, p. 711

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

4. ANS: 2, 3, 4

To prevent sensory overload, minimize unnecessary light, plan care to provide uninterrupted periods of sleep, and speak to the patient in a moderate tone of voice using a calm and confident manner. Television can be used to provide sensory stimuli, but not to prevent sensory overload. When used, it should not be left on indiscriminately

PTS: 1 DIF: Moderate REF: V1, pp. 720-721

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

5. ANS: 3, 4

Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the siderails up. If the patients blink reflex is absent or her eyes do not close totally, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. Providing touch will also help prevent sensory deficit; however, it is not a safety measure.

PTS: 1 DIF: Difficult REF: V1, p. 724

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

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