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 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 2 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.
Question 3 of 5
A nurse is caring for a patient with a traumatic spinal cord injury that resulted in paraplegia (paralysis) and sensory loss from the waist down. When obtaining data about this patient, what component of sensory function does the nurse plan to assess?
Correct Answer: A
Rationale: Trauma to the spinal cord can cause both motor and sensory loss, interfering with transmission of tactile stimuli. Although the other options may be assessed, they do not relate to the spinal cord injury.
Question 4 of 5
A school nurse is performing vision screenings on middle-school children. The nurse notes a student squinting and that their visual acuity using a Snellen's eye chart is 20/160. When questioned, the student states their grades have dropped, and they are having difficulty completing work on time. What is the best recommendation for the nurse to make to the student's guardian(s)?
Correct Answer: D
Rationale: Visual acuity of 20/160 indicates myopia; this student sees at 20 feet what a person with normal vision can see at 160 feet. The impaired vision is interfering with their academic performance, and further assessment by an eye care professional is indicated.
Question 5 of 5
A nurse is caring for a patient with a severe hearing deficit who reads lips and uses sign language. Which nursing intervention would best prevent sensory alterations for this patient?
Correct Answer: C
Rationale: Providing opportunities for the patient to socialize builds on their strength of being able to lip-read and helps prevent sensory deprivation from hearing loss.