ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 45 Questions
Question 1 of 5
Which of the following parameters must be in place to ensure a successful resolution of the reason for the Pirolla's initial visit? Select all that apply.
Correct Answer: A,B,D,E
Rationale: The goal of the interventions is to improve Mr. Pirolla's ability to socialize despite sensory impairments. Using adaptive devices (
A), improved communication without yelling (
B), enjoying family visits (
D), and contentment with their adjusted social life (E) indicate successful management of sensory deficits. Regaining 20/20 vision (
C) is unrealistic for age-related sensory loss, and resuming a fully active social life (F) may not be feasible given his limitations.
Question 2 of 5
A nurse in a long-term care facility notes that a patient with limited activity related to severe rheumatoid arthritis is at risk for sensory deprivation. Based on this information, which interventions will the nurse include in the care plan? Select all that apply.
Correct Answer: B,D,E
Rationale: For a patient who has sensory deprivation, the nurse provides interaction with children and pets, ensures that the patient shares meals with other patients, and discourages the use of sedatives. Using a lower tone (pitch) of voice is appropriate for a patient with a hearing deficit. Decreasing environmental noise helps relieve sensory overload. Providing adequate lighting and removing clutter is an intervention for a vision deficit.
Question 3 of 5
A nurse in the neonatal intensive care unit (ICU) is planning care to reduce inappropriate sensory stimulation to their patients. Which interventions could the nurse include in the care plan? Select all that apply.
Correct Answer: C,D
Rationale: The neonatal ICU may be a source of excess sensory stimulation. It is recommended that medically fragile infants receive limited light (visual stimuli) to simulate being in the womb as well as reduced vestibular stimulation. The nurse avoids activities that promote stimulation in this population including soothing, holding, rocking, and changes of position (tactile and kinesthetic sensations), singing and speaking to the neonate (auditory sensations), and changing patterns of light and shade, such as through the use of mobiles and bright objects (visual sensations).
Question 4 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 5 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.