Nokea
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.
- A. Providing bright mobiles and objects for the neonate to look at
- B. Rocking the neonate frequently, especially when crying
- C. Maintaining reduced ambient light, similar to conditions in the womb
- D. Reducing vestibular stimulation, such as rocking
- E. Playing music or singing to the neonate to stimulate hearing
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).
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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.
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 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.
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.
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.