Chapter 38 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 38

Question 1

Type: MCSA

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

1. Use the clock face as a format for describing the position of food on meal trays.

2. Provide all teaching materials in very large font.

3. Ensure that the client has assistance when ambulating.

4. Use only nonirritating soaps for bathing.

Correct Answer: 3

Rationale 1: This would be appropriate for the client with an alteration in vision.

Rationale 2: This would be appropriate for the client with an alteration in vision.

Rationale 3: Kinesthetic sensation refers to the awareness of the position and movement of body parts. The client with impairment of this sensation may be prone to injury by falling and should be assisted when ambulating.

Rationale 4: This intervention would be appropriate for a client having a tactile or skin disorder.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function.

MNL Learning Outcome: 4.3.3. Implement the nursing process in the care of the client with diminished mobility.

Page Number: 904

Question 2

Type: MCSA

A client diagnosed with congestive heart failure has been treated for many years with intravenous furosemide (Lasix). What sensory impairment should the nurse assess in this client?

1. Loss of ability to taste

2. Hearing loss

3. Vision loss

4. Loss of ability to smell

Correct Answer: 2

Rationale 1: Furosemide (Lasix) does not affect the ability to taste.

Rationale 2: Furosemide (Lasix) can be ototoxic if taken over long periods of time. The nurse would monitor for hearing loss.

Rationale 3: Furosemide (Lasix) does not affect vision.

Rationale 4: Furosemide (Lasix) does not affect the ability to smell.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances.

MNL Learning Outcome: 4.14.1. Consider how drugs act on the body and how the body acts on drugs in the care of the client.

Page Number: 906

Question 3

Type: MCSA

A client has been treated for diabetes mellitus since childhood. Currently, the clients blood glucose reading is 180 mg/dl. For which sensory disturbance should the nurse assess in this client?

1. Loss of ability to taste

2. Hearing loss

3. Vision loss

4. Loss of ability to smell

Correct Answer: 3

Rationale 1: Uncontrolled diabetes mellitus does not affect the ability to taste.

Rationale 2: Uncontrolled diabetes mellitus does not affect hearing.

Rationale 3: Uncontrolled diabetes mellitus is a leading cause of blindness in the United States.

Rationale 4: Uncontrolled diabetes mellitus does not affect the ability to smell.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances.

MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety.

Page Number: 906

Question 4

Type: MCSA

The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What initial assessment technique should the nurse employ?

1. Schedule a Weber and Rinne test.

2. Observe the clients interaction with significant others.

3. Use an otoscope to visualize the inner ear.

4. Confront the client with the nurses suspicion.

Correct Answer: 2

Rationale 1: The Weber and Rinne test may be a part of assessment, but will not yield as much information as the simple observation.

Rationale 2: The most telling of these options would be to observe the clients interactions with significant others. The nurse should assess for frequent requests to repeat, inattention to conversation, turning one ear to the conversation, and lip-reading.

Rationale 3: Use of an otoscope may be a part of assessment, but will not yield as much information as the simple observation.

Rationale 4: The client has already denied a hearing problem, so confronting the client with the nurses suspicion will probably only serve to alienate the client from the nurse.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Describe essential components in assessing a clients sensory-perception function.

MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety.

Page Number: 914

Question 5

Type: MCSA

The nurse is providing education for the parents of a 7-month-old child who has just been diagnosed with a hearing loss. What guidance should the nurse provide?

1. Expect that the child will be enrolled in a special hearing intervention program immediately.

2. Keep your child in a quiet environment until additional testing is done.

3. Interventions to support hearing are not useful until the child is at least 9 months old.

4. Hearing loss is not serious until 1 year of age.

Correct Answer: 1

Rationale 1: The Centers for Disease Control and Prevention (CDC) expects that all infants identified with hearing loss will receive early intervention services prior to age 36 months.

Rationale 2: The child should be stimulated with color, smells, body positions, and textures to develop compensatory mechanisms for the hearing loss.

Rationale 3: The Centers for Disease Control and Prevention (CDC) expects that all infants identified with hearing loss will receive early intervention services prior to age 36 months.

Rationale 4: Hearing loss is serious from birth.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function.

MNL Learning Outcome: 4.1.1. Recognize factors that affect client safety.

Page Number: 909

Question 6

Type: MCSA

The odor from a hospitalized clients draining wound permeates the room and is very overwhelming and distracting to the client and the staff. What intervention would be most helpful?

1. Spray the room routinely with a floral room spray.

2. Instill a vinegar solution into the wound.

3. Keep the wound dressing dry and clean.

4. Burn a candle in the room.

Correct Answer: 3

Rationale 1: Spraying the room with a floral spray will add to the sensory overload.

Rationale 2: Vinegar is not instilled into wounds.

Rationale 3: The best way to keep odors controlled is to keep the wound dressing dry and clean.

Rationale 4: Burning a candle will add to the sensory overload, and burning candles are not safe in the hospital environment.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 914

Question 7

Type: MCSA

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

1. Walk slightly behind the client.

2. Walk 1 foot in front of the client.

3. Walk on the right side of the client.

4. Walk on the left side of the client.

Correct Answer: 2

Rationale 1: Walking behind the client would be unsafe.

Rationale 2: The nurse should walk about 1 foot in front of the client, offering the client an arm.

Rationale 3: The side the nurse walks on will depend upon the preference of the client.

Rationale 4: The side the nurse walks on will depend upon the preference of the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 910

Question 8

Type: MCSA

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

1. As reversible confusion

2. As sundown syndrome

3. As delirium

4. As dementia

Correct Answer: 3

Rationale 1: The nurse has no way of knowing if this clients confusion is reversible.

Rationale 2: There is not enough information to determine if the client is experiencing sundown syndrome.

Rationale 3: Delirium is acute confusion caused by illness, medication, or a change in environment and is the appropriate documentation for this client.

Rationale 4: Dementia is chronic confusion with symptoms that are gradual in onset and are irreversible.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 915

Question 9

Type: MCMA

The nurse is concerned that a client is not aware of being in the hospital. For what aspects of the sensory process should the nurse assess the client?

Standard Text: Select all that apply.

1. Speech

2. Stimuli

3. Receptor

4. Perception

5. Impulse conduction

Correct Answer: 2, 3, 4, 5

Rationale 1: Speech is not an aspect of the sensory process.

Rationale 2: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these aspects is a stimulus, which is an agent or act that stimulates a nerve receptor.

Rationale 3: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is a receptor, which is the ability to convert the stimulus to a nerve impulse.

Rationale 4: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is perception, which is the awareness and interpretation of the stimuli in the brain.

Rationale 5: For an individual to be aware of the surroundings, four aspects of the sensory process must be present. One of these is impulse conduction, which means the impulse travels along the nerve pathways to either the spinal cord or directly to the brain.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Discuss the components of the sensory-perception process.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 904

Question 10

Type: MCSA

A client can be aroused only with extreme or repeated stimuli. How should the nurse document this clients behavior?

1. Somnolent

2. Disoriented

3. Comatose

4. Semicomatose

Correct Answer: 4

Rationale 1: The somnolent client is very drowsy, but will respond to stimuli.

Rationale 2: A disoriented client is alert, but not oriented to time, place, or person.

Rationale 3: The comatose client is not arousable.

Rationale 4: Because this client can be aroused with extreme stimuli or repeated stimuli, the correct description is semicomatose.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Develop nursing diagnoses and outcome criteria for clients with impaired sensory function.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 905

Question 11

Type: MCSA

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

1. Background noise such as music will keep this client calm.

2. Activities should be scheduled at the same time each day.

3. Pain mediation will increase dementia.

4. It is important to talk with the client throughout procedures.

Correct Answer: 2

Rationale 1: The client typically is better oriented when it is quiet.

Rationale 2: The client with dementia benefits from a routine schedule of activities.

Rationale 3: Pain should be controlled.

Rationale 4: Procedures should be explained in direct, clearly understandable terms, but the nurse should avoid chatter.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Identify strategies to promote a therapeutic environment for the client with acute confusion/delirium.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 915

Question 12

Type: MCSA

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

1. Acute Confusion

2. Altered Role Performance

3. Disturbed Sensory Perception

4. Disturbed Thought Processes

Correct Answer: 4

Rationale 1: Clients with Alzheimers disease are more likely to exhibit chronic confusion.

Rationale 2: There is no evidence to support Altered Role Performance.

Rationale 3: Disturbed Sensory Perception is more useful with the client who has difficulty related to sensory input (perception).

Rationale 4: Because this client has dementia, which interferes with the ability to interpret stimuli, the correct diagnosis problem statement is Disturbed Thought Processes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Develop nursing diagnoses and outcome criteria for clients with impaired sensory function.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 908

Question 13

Type: MCSA

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

1. Use short phrases.

2. Overarticulate words.

3. Vary the volume of the voice.

4. Face the client during conversation.

Correct Answer: 4

Rationale 1: The nurse should use longer phrases that more completely explain concepts.

Rationale 2: Overarticulation of words makes them difficult to lip-read.

Rationale 3: The volume of the voice should be consistent.

Rationale 4: The best intervention is to face the client during conversation so that the client can employ any lip-reading skills.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 915

Question 14

Type: MCMA

A client is experiencing changes in taste. What can the nurse do to improve this clients gustatory sense?

Standard Text: Select all that apply.

1. Suggest eating each food separately.

2. Offer foods with a variety of flavors.

3. Recommend eating foods that are cold.

4. Promote sips of water between eating different foods.

5. Encourage the client to consume foods of different textures.

Correct Answer: 1, 2, 4, 5

Rationale 1: To improve the sense of taste, the nurse should encourage the client to eat each food separately.

Rationale 2: To improve the sense of taste, the nurse should encourage the client to eat foods with a variety of flavors.

Rationale 3: Eating cold foods will not improve the clients sense of taste.

Rationale 4: To improve the sense of taste, the nurse should encourage the client to take sips of water between eating different foods.

Rationale 5: To improve the sense of taste, the nurse should encourage the client to consume foods of different textures.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Discuss nursing interventions to promote and maintain sensory function.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 911

Question 15

Type: MCSA

The family of a client in the hospital is concerned about the constant noise in the care area. Which health care professionals have the greatest control over the level of sensory input in the hospital?

1. Physicians

2. Administrators

3. Nurses

4. Planners

Correct Answer: 3

Rationale 1: Physicians are not at the bedside as much as nurses.

Rationale 2: Administrators are not at the bedside as much as nurses.

Rationale 3: Nurses have the greatest amount of control over the level of sensory input in the hospital. Nurses can decrease sensory overload by controlling lights, noise, odors, and pain. Nurses can also increase sensory input by stimulating the client as appropriate.

Rationale 4: Planners are not at the bedside as much as nurses.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Describe factors that influence sensory function.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 908

Question 16

Type: MCMA

The nurse documents that a client is fully conscious. What did the nurse assess in this client?

Standard Text: Select all that apply.

1. Client responded to verbal stimuli.

2. Client responded to written words.

3. Client oriented to time, place, and person.

4. Client demonstrated poor memory.

5. Client alert.

Correct Answer: 1, 2, 3, 5

Rationale 1: A characteristic of being fully conscious is responding to verbal stimuli.

Rationale 2: A characteristic of being fully conscious is responding to written words.

Rationale 3: A characteristic of being fully conscious is being oriented to time, place, and person.

Rationale 4: Demonstrating poor memory is a characteristic of being confused.

Rationale 5: A characteristic of being fully conscious is being alert.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Describe essential components in assessing a clients sensory-perception function.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 905

Question 17

Type: MCSA

A client asks the nurse to please close the door when entering or exiting the room because the noise is more than the client is used to because he lives alone. The nurse identifies the reason for this clients response to sensory stimuli as being due to which factor?

1. Lifestyle

2. Developmental stage

3. Culture

4. Illness

Correct Answer: 1

Rationale 1: Lifestyle influences the quality and quantity of stimulation to which an individual is accustomed. A client who lives alone is exposed to fewer, less diverse stimuli.

Rationale 2: There is no information to support that the clients response to sensory stimuli is because of developmental stage.

Rationale 3: There is no information to support that the clients response to sensory stimuli is because of culture.

Rationale 4: There is no information to support that the clients response to sensory stimuli is because of illness.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe factors that influence sensory function..

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 906

Question 18

Type: MCMA

The nurse is concerned that a client is experiencing sensory deprivation. What did the nurse assess to make this clinical decision?

Standard Text: Select all that apply.

1. Excessive sleeping

2. Confusion at night

3. Anger over minor issues

4. Easily distracted

5. Sitting quietly reading a book

Correct Answer: 1, 2, 3, 4

Rationale 1: A clinical manifestation of sensory deprivation is excessive sleeping.

Rationale 2: A clinical manifestation of sensory deprivation is nocturnal confusion.

Rationale 3: A clinical manifestation of sensory deprivation is annoyance over small matters.

Rationale 4: A clinical manifestation of sensory deprivation is a decreased attention span.

Rationale 5: Sitting quietly reading a book is not a clinical manifestation of sensory deprivation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 906

Question 19

Type: MCMA

The nurse suspects a client will develop sensory overload. What characteristics did the nurse observe in the client?

Standard Text: Select all that apply.

1. Ongoing pain

2. Confusion at night

3. Inability to sleep

4. Easily angered

5. Worrying about upcoming diagnostic tests

Correct Answer: 1, 3, 5

Rationale 1: Pain can contribute to sensory overload.

Rationale 2: Nocturnal confusion is a manifestation of sensory deprivation.

Rationale 3: Sleeplessness can contribute to sensory overload.

Rationale 4: Being easily annoyed is a manifestation of sensory deprivation.

Rationale 5: Worry can contribute to sensory overload.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 906

Question 20

Type: MCSA

A client is hospitalized for treatment of a new disorder. While admitted, the client receives no telephone calls or visitors. The nurse should assess which aspect of the clients sensory-perception function?

1. Risk for sensory overload

2. Social support network

3. Mental status

4. Environment

Correct Answer: 2

Rationale 1: The lack of telephone calls or visitors will not be assessed through assessing the clients risk for sensory overload.

Rationale 2: The degree of isolation a person feels is significantly influenced by the quality and quantity of support from family members and friends. The nurse should assess the clients living arrangements, visitors, and any signs indicating social deprivation, such as withdrawal from contact with others to avoid embarrassment or dependence on others, negative self-image, reports of lack of meaningful communication with others, and absence of opportunities to discuss fears or concerns that facilitate coping mechanisms.

Rationale 3: The lack of telephone calls or visitors will not be assessed through a mental status assessment.

Rationale 4: The lack of telephone calls or visitors will not be assessed through an environmental assessment.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload. 5. Discuss factors that place a client at risk for sensory disturbances.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 908

Question 21

Type: MCMA

The nurse is assessing a client for possible sensory deprivation. What findings would indicate the client is at risk for developing this sensory disorder?

Standard Text: Select all that apply.

1. Client has severe pain.

2. Client has impaired vision.

3. Client is unable to ambulate.

4. Client is on medication that alters sensory perception.

5. Client has no family in the immediate area.

Correct Answer: 2, 3, 4, 5

Rationale 1: Severe pain increases a clients risk for sensory overload.

Rationale 2: Impaired vision increases a clients risk for developing sensory deprivation.

Rationale 3: Mobility restrictions increase a clients risk for developing sensory deprivation.

Rationale 4: Medications that affect the central nervous system increase a clients risk for developing sensory deprivation.

Rationale 5: Limited social contact with family and friends increases a clients risk for developing sensory deprivation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Describe factors that influence sensory function. 3. Identify clinical signs and symptoms of sensory deprivation and overload.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 908

Question 22

Type: MCSA

The nurse is identifying diagnoses appropriate for a client recovering from cataract surgery who lives alone. Which diagnosis would be the priority for this client?

1. Social Isolation

2. Risk for Impaired Skin Integrity

3. Disturbed Sensory Perception

4. Risk for Injury

Correct Answer: 4

Rationale 1: Social Isolation would be appropriate for the client with long-term vision changes but not one with an acute change as in cataract surgery.

Rationale 2: Risk for Impaired Skin Integrity is used to describe clients who have altered tactile sensation.

Rationale 3: Disturbed Sensory Perception is used to describe clients whose perception has been altered by physiological factors such as pain, sleep deprivation, immobility, disease states such as CVA, or brain trauma.

Rationale 4: Because the client lives alone and is recovering from cataract surgery, the clients risk for injury is great.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 6. Develop nursing diagnoses and outcome criteria for clients with impaired sensory function.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 909

Question 23

Type: MCSA

The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception, Auditory. What would indicate that interventions to address this diagnosis have been successful?

1. Client places hearing aid on beside table when not in use.

2. Client does not respond appropriately to questions.

3. Client demonstrates use and care of hearing aid.

4. Client demonstrates difficulty with problem solving.

Correct Answer: 3

Rationale 1: The clients placing the hearing aid on a bedside table when not in use would indicate that interventions were not successful.

Rationale 2: The clients responding inappropriately to questions would indicate that interventions were not successful.

Rationale 3: Outcome criteria that indicate interventions to address Disturbed Sensory Perception, Auditory have been successful would include the clients demonstrating use and care of the hearing aid.

Rationale 4: The clients demonstrating difficulty with problem solving is an indication of sensory overload.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 8. Identify strategies to promote a therapeutic environment for the client with acute confusion/delirium.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 911

Question 24

Type: MCMA

A client is experiencing acute confusion. What nursing actions would be appropriate for this client?

Standard Text: Select all that apply.

1. Eliminate unnecessary noise.

2. Keep eyeglasses within reach.

3. Place a calendar in the room, and identify each day.

4. Keep the room well lit during waking hours.

5. Provide dark glasses.

Correct Answer: 1, 2, 3, 4

Rationale 1: Eliminating unnecessary noise would help the client who is experiencing acute confusion.

Rationale 2: Keeping eyeglasses within reach would help the client who is experiencing acute confusion.

Rationale 3: Placing a calendar in the room and identifying each day would help the client who is experiencing acute confusion.

Rationale 4: Keeping the room well lit during waking hours would help the client who is experiencing acute confusion.

Rationale 5: Providing dark glasses would help the client who is experiencing sensory overload.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Identify strategies to promote a therapeutic environment for the client with acute confusion/delirium.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 917

Question 25

Type: MCMA

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

Standard Text: Select all that apply.

1. Inability to follow directions

2. Mood swings

3. Decreased appetite

4. Complaints of dizziness

5. Answering questions incorrectly

Correct Answer: 1, 2, 4, 5

Rationale 1: The client who has difficulty hearing might have an inability to follow directions because the directions were not heard.

Rationale 2: The client who has difficulty hearing might have mood swings because of the stress of not hearing well.

Rationale 3: Decrease in appetite is not generally associated with hearing loss.

Rationale 4: The client who has difficulty hearing might have complaints of dizziness associated with inner ear disturbances.

Rationale 5: The client who has difficulty hearing might answer questions incorrectly because a question was not heard or was misinterpreted.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Discuss factors that place a client at risk for sensory disturbances.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 907

Question 26

Type: MCMA

The nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to come to this conclusion?

Standard Text: Select all that apply.

1. Sleeplessness

2. Anxiety

3. Apathy

4. Racing thoughts

5. Somatic complaints

Correct Answer: 1, 2, 4

Rationale 1: Sleeplessness is an indication of sensory overload.

Rationale 2: Anxiety is an indication of sensory overload.

Rationale 3: Apathy is associated with sensory deprivation.

Rationale 4: Racing thoughts are an indication of sensory overload.

Rationale 5: Somatic complaints are an indication of sensory deprivation.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Identify clinical signs and symptoms of sensory deprivation and overload.

MNL Learning Outcome: 2.2.1. Examine the components of sensory perception and the associated nursing care.

Page Number: 906

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