3234 Exam 4 Fundamentals Questions

3234 Exam 4 Fundamentals Questions & Answers Ch 43 #1 A nurse who is assessing an older female patient in a long term care facility notes that the patient is at risk for sensory deprivation related to severe rheumatoid arthritis limiting her activity. Which interventions would the nurse recommend based on this finding. Select al that apply

• use a lower tone when communicating with the patient
• Provide interaction with children and pets
• Decrease environmental noise
• Ensure that the patient shares meals with other patients
• Discourage use of sedatives
• Provide adequate lighting and clear pathways of clutter - correct answerB, D, E

Provide interaction with children and pets, ensure that patient shares meals, and discourage use of sedatives Using lower tone of voice is appropriate for hearing deficit patient, decrease environmental noise is for sensory overload and providing adequate lighting and removing clutter is for vision deficit Ch 43 #2 A nurse is assessing a78 year old male patient for kinesthetic and visceral disturbances. Which techniques would the nurse use for this assessment? Select all that apply.

• nurse asks the patient if he is bored and if so, why
• The nurse asks the patient if anything interferes with the functioning of his senses
• The nurse asks the patient if he noticed any changes in the way he perceives his

body

• the nurse asks the patient if he has found it difficult to communicate verbally
• the nurse notes if the patient withdraws from being touched
• The nurse notes if the patient seems unsure of his body parts/position - correct

answerC, D, E, F Kinesthetic and visual disturbances: assess for perceived body changes inside and out, and changes in body parts or position Ch 43 #3 A nurse asks a patient to close her eyes, state when she feels something, and describe the feeling. The nurse then brushes the patient's skin with a cotton ball, and touches the patient's skin with both sides of a safety pin. Which sense is the nurse assessing?

• Gustatory
• Olfactory
• Tactile
• Kinesthetic - correct answerC

Tactile: touch 1 / 3

Gustatory: taste

Olfactory: smell

Kinesthetic: body position

Ch 43 #4 A nurse observes that a patient who has cataracts is sitting closer to the TV than usual. The nurse would interpret that the etiologic basis of this sensory problem is

an alteration in:

• environmental stimuli
• sensory reception
• nerve impulse conduction
• impulse translation - correct answerB

Cataracts interfere with ability to receive visual stimuli: altered sensory receptoin Ch 43 #5 Which action would be most important for a nurse to include in the plan of care for a patient who is 85 and has prebycusis?

• Obtaining large print written material
• Speaking distinctly, using lower frequencies
• Decreasing tactile stimulation
• Initiating a safety program to prevent falls - correct answerB

Prebycusis: normal loss of hearing as a result of aging process

Ch 43 #6 A patient is in the late stages of AIDS, which is now affecting his brain as well as other major organ systems. The patient confides to the nurse that he feels terribly alone because most of his friends are afraid to visit. The nurse determines that the least

likely underlying etiology for his sensory problems would be:

• stimulation
• Reception
• tranmission-perception-reaction
• emotional responses - correct answerD

Emotional responses are an effect of sensory deprivation, not the underlying etiology for this condition Receiving decreased environment stimuli from his friends; problems with reception because of major organ involvement; impaired brain function will impair transmisison- perception-reaction Ch 43 #7 Which patient would a nurse assess as being at greatest risk for sensory deprivation?

• an odler man confined to bed at home after a stroke
• an adolescent in an oncology unit working on homework supplied by friends
• A woman in labor 2 / 3

D a toddler in a playroom awaiting same day surgery - correct answerA Ch 43 #8 A patient in an intensive care burn unit for 1 week is in pain much of the time and has his face and both arms heavily bandaged. His wife visits every evening for 15 minutes at 6, 7, and 8pm. A heart monitor beeps for a patient on one side, and another patient moans frequently. Assessment would suggest that the patient probably is

experiencing:

• sufficient sensory stimulation
• deficient sensory stimulation
• Excessive sensory stimulation
• both sensory deprivation and overload - correct answerD

Bandages may result in deficient sensory stimulation and the monitors and other sounds in the intensive care burn unit may cause a sensory overload Ch 43 #9 A patient's spinal cord was severed, and he is paralyzed from the waist down.When obtaining data about this patient, which component of the sensory experience would be most important for the nurse to assess?

• transmission of tactile stimuli
• adequate stimulation in the environment
• reception of visual and auditory stimuli
• general orientation and ability to follow commands - correct answerA

Ch 43 #10 A nurse is diagnosing an 11 year old sixth grade student following a physical assessment. The nurse notes that the student's grades have dropped, she has difficulty completing her work on time, and she frequently rubs her eyes and squints. Her visual acuity on the Snellen's eye chart is 160/20. Which nursing diagnosis would be most appropriate?

• Deficient knowledge related to visual impairment
• ineffective role performance related to visual impairment
• disturbed body image related to visual impairment
• delayed growth and development related to visual impairment - correct answerB

Ch 43 #11 A nurse is caring for a male patient with a severe hearing deficit who is able to read lips and use sign language. Which nursing intervention would be best to prevent sensory alterations for this patient?

• Turn the radio or TV volume up very loud and close the door to his room
• Prevent embarrassment and emotional discomfort as much as possible
• Provide daily opportunity for him to participate in a social hour with 6-8 people
• Encourage daily participation in exercise and physical activity - correct answerC
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