ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 45 : Sensory Functioning Questions
Question 1 of 5
A nurse is assessing a patient for gustatory disturbances. Which question asked by the nurse would be appropriate for this assessment?
Correct Answer: A
Rationale: When the nurse asks: "Have you been experiencing any strange tastes lately?" the nurse is assessing for gustatory disturbances. The question: "Have you smelled odors lately that others cannot smell?" assesses for olfactory disturbances. When the nurse asks: "Can you tell me what I am placing in your hand right now?" the nurse is assessing for tactile disturbances. The question "Have you found it difficult to communicate verbally?" assesses for transmission-perception-reaction.
Question 2 of 5
A nurse observes that a patient with a history of cataracts is sitting closer to the television than usual. When assessing the patient, which additional findings will the nurse anticipate?
Correct Answer: A
Rationale: Cataracts, clouding of the crystalline lens, cause altered sensory reception by interfering with the patient's ability to receive visual stimuli. The other options are not characteristic of cataracts.
Question 3 of 5
A nurse supervises APs in a long-term care facility where many residents have presbycusis. What directions will the nurse give the APs to best promote communication with these patients?
Correct Answer: B
Rationale: Presbycusis is an expected decrease or loss of hearing as a result of the aging process. Speaking distinctly in lower frequencies is indicated. Obtaining large-print written material is appropriate for visual alterations. Decreasing tactile stimulation is appropriate for a patient with a sensory overload, and initiating a safety program to prevent falls is appropriate for a patient experiencing kinesthetic/visceral alterations.
Question 4 of 5
A patient is in the late stages of AIDS, which has affected their brain function and memory. The patient reports loneliness because his friends "are afraid to visit." Based on this data, what nursing intervention would best help meet the patient's need for sensory stimulation?
Correct Answer: D
Rationale: This patient is receiving decreased environmental stimuli (e.g., from lack of visitors) and may experience problems with reception because of brain involvement. Arranging for a volunteer to sit with the patient provides social interaction, addressing the loneliness and sensory deprivation.
Question 5 of 5
A home care nurse is visiting a group of patients. Which patient does the nurse identify as having the highest risk for sensory deprivation?
Correct Answer: A
Rationale: The patient confined to bed rest at home has a high risk for greatly reduced environmental stimuli. The other patients are in environments in which environmental stimuli are present.