Nokea
A home care nurse is visiting a group of patients. Which patient does the nurse identify as having the highest risk for sensory deprivation?
- A. Older adult confined to bed at home after a stroke
- B. Adolescent in an oncology unit working on homework
- C. Pregnant patient in active labor
- D. Toddler awaiting same-day surgery in a playroom
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.
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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?
- A. Provide patients with large-print written menus.
- B. Speak clearly and distinctly, using a lower tone of voice.
- C. Decrease tactile stimulation.
- D. Remind all patients to "call, not fall."
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.
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.
- A. Mr. Pirolla is looking into adaptive devices (hearing aid, new glasses) to make socializing more possible for him.
- B. Mrs. Pirolla reports that she no longer has to yell to get her husband's attention and that the TV can be kept at a moderate volume.
- C. Mr. Pirolla regains 20/20 vision.
- D. Mrs. Pirolla reports that her husband seems to be enjoying family visits more and no longer withdraws to his study.
- E. Mrs. Pirolla reports that they both seem content with their "new normal" social life.
- F. Mrs. Pirolla reports that they have pretty much resumed their active social life.
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.
A home care nurse is visiting an older adult with long-standing diabetes who reports pain and numbness in their feet. What education is most appropriate for this patient?
- A. Take acetaminophen or over-the-counter analgesic when pain occurs.
- B. Increase intake of foods containing vitamins B6, B12, and folate.
- C. Explain that phantom limb pain can become chronic, but psychosocial support can help.
- D. Validate the patient's understanding of foot care for patients with diabetes.
Correct Answer: D
Rationale: Patients with diabetes can develop peripheral neuropathy resulting in loss of sensation and reduced blood flow. The loss of sensation can promote injury the patient does not readily notice. Therefore, those with diabetes must perform special foot care and visual inspection.
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?
- A. Turning the radio or television volume up very loud and closing the door to his room
- B. Preventing embarrassment and emotional discomfort as much as possible
- C. Providing daily opportunities for them to participate in a social hour with six to eight people
- D. Encouraging daily participation in exercise and physical activity
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.
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?
- A. Clouding of the lens in one or both eyes
- B. Eye pain when performing close work
- C. Abrupt loss of vision
- D. Loss of central vision
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.