Concept 25: Sensory Perception My Nursing Test Banks

Concept 25: Sensory Perception

Test Bank

MULTIPLE CHOICE

1. Mrs. J, a 57-year-old woman, walks into the emergency department with complaints of not feeling well. Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that Mrs. J has an open wound on the bottom of her foot, but the patient states she is not aware of this. The nurse interprets this response as

a.

normal in the older adult.

b.

a need for the patient to be evaluated for cognitive impairment.

c.

a side effect of anti-hypertensive medication.

d.

pathologic impairment of sensory responses.

ANS: D

Though at 57 she is borderline for older, this degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely Ms. J has diabetes, which is causing decreased sensation. The not feeling well is secondary to a change in blood sugar secondary to the wound response.

REF: 264

OBJ: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation

2. The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements?

a.

This will help us to identify your babys risk for ear infections the first year of life.

b.

Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother.

c.

Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child.

d.

Imitation of sounds is the first step in language development, and it is important to identify alterations early.

ANS: D

Newborn screening of hearing does not identify risk of infection but only of sensory responses. The babys response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.

REF: 264 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

3. Mr. Smith is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. The nurses best response would be which of the following?

a.

Your wife should increase the spices in your food, as the pneumonia changes your sense of smell.

b.

Notify your doctor immediately, because this is a concerning reaction to the medication.

c.

You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection.

d.

You should see an improvement in the next week or so. Call if this continues.

ANS: D

Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.

REF: 260

OBJ: NCLEX Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

4. Mr. K, an 80-year-old patient, is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident in when the daughter says which of the following?

a.

I will make sure that Dad always wears warm socks.

b.

Dad needs to wear his glasses so he can delay the onset of macular degeneration.

c.

I will ask the home health aide to carefully inspect Dads feet every day when she helps him bathe.

d.

We will give him only warm foods, so that he doesnt burn his mouth.

ANS: C

Diabetes increases risk of peripheral neuropathy, and it is hard to inspect ones own feet. Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.

REF: 265 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

5. The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. To provide recreational activities during the rehabilitation phase, the nurse should

a.

place the television to the left or right of patients visual field.

b.

encourage the patient to learn braille.

c.

suggest use of talking books.

d.

provide headphones for listening to music.

ANS: C

Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.

REF: 266 OBJ: NCLEX Client Needs Category: Psychosocial Integrity

6. The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, she would

a.

notify the physician.

b.

document the finding in the records.

c.

recheck the reflex after several hours.

d.

monitor the eye movements and pupil reactions closely.

ANS: A

The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.

REF: 265 OBJ: NCLEX Client Needs Category: Physiological Integrity

7. The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction?

a.

I will take my child to the audiologist because he doesnt seem to hear me except when I look directly at him.

b.

Both of my children have the same eye medication, which is a real bonus, because I need only buy one bottle.

c.

Making my child wear ear plugs when she goes to a rock concert may save her hearing!

d.

I see now why when my child has a cold, he complains about everything tasting blah!

ANS: B

Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.

REF: 261|264|265 OBJ: NCLEX Client Needs Category: Health Promotion and Maintenance

8. During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patients wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for

a.

tympanoplasty.

b.

irrigation of the ear.

c.

pure tone test.

d.

otoscopic exam by a specialist.

ANS: B

The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.

REF: 264-266 OBJ: NCLEX Client Needs Category: Physiological Integrity

MULTIPLE RESPONSE

1. An 80-year-old patient has a hearing deficit which he states is getting worse; his hearing aid needs to be replaced. He states he attends church but cannot understand the sermon anymore. He hates to go out to events because his hearing aid makes everything noisy. He notes nothing is the same. During the assessment he asks the nurse to repeat the question frequently. Nursing diagnoses would include which of the following? (Select all that apply.)

a.

Altered growth and development

b.

Social isolation

c.

Chronic confusion

d.

Activity intolerance

e.

Hopelessness

f.

Spiritual distress

ANS: B, E, F

His lack of hearing has interfered with his social activities, including his church. There is no support for inability to be active physically, nor does he show signs of confusion. Because the loss is recent, growth and development were not affected.

REF: 261-262|266 OBJ: NCLEX Client Needs Category: Psychosocial Integrity

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