Nokea
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.
- A. Using a lower tone when communicating with the patient
- B. Providing interaction with children and pets
- C. Decreasing environmental noise
- D. Ensuring that the patient shares meals with other patients
- E. Discouraging the use of sedatives
- F. Providing adequate lighting and clear pathways of clutter
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.
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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.
In a group home where most residents have varying degrees of visual or hearing impairments and some are periodically confused, what nursing action is essential?
- A. Maintaining safety and preventing sensory deterioration
- B. Insisting that residents participate in as many self-care activities as possible
- C. Emphasizing and reinforcing individual patient strengths
- D. Encouraging reminiscence and life review in groups
Correct Answer: A
Rationale: Safety is a basic physiologic need that must be met before higher-level needs such as love and belonging, self-esteem, and self-actualization can be met.
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.
When caring for an older adult who repeatedly states their food does not taste as good as it used to, a nurse explains that which factors can contribute to loss of taste as patients age? Select all that apply.
- A. Decreased sense of smell
- B. Presbycusis
- C. Medications
- D. Diseases
- E. Tobacco use
- F. Presbyopia
Correct Answer: A,C,D,E
Rationale: As the patient ages, gustatory senses, along with sense of smell, some medications, and smoking can blunt the taste (gustatory sense). Presbycusis refers to the reduced ability to hear, and presbyopia refers to the inability of the lens to accommodate to near (or far) objects.
A nurse is assessing a patient for gustatory disturbances. Which question asked by the nurse would be appropriate for this assessment?
- A. "Have you been experiencing any loss of taste or strange tastes lately?"
- B. "Have you smelled odors lately that others cannot smell?"
- C. "Can you tell me what object I am placing in your hand right now?"
- D. "Have you found it difficult to communicate verbally?"
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.