Nokea
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.
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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.
A school nurse is teaching a group of high school students about preventing hearing loss. What preventative actions does the nurse recommend? Select all that apply.
- A. Use earphones when listening to music, podcasts, or other programs.
- B. Do not insert objects such as cotton-tipped applicators into the ear.
- C. Avoid playing contact sports.
- D. Use ear protection when performing tasks with loud sounds.
- E. It is best to begin screening for hearing loss at age 18 years.
Correct Answer: B,D
Rationale: To prevent hearing loss, the nurse teaches students to avoid concentrating sound in the ear canal, such as when using earphones, and to use ear protection for loud activities. Inserting objects into the ear canal can cause damage.
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 caring for an older adult who has a severe visual deficit related to glaucoma. Which nursing action is most appropriate when providing care for this patient?
- A. Assisting the patient to ambulate by walking slightly behind them and grasping the arm
- B. Concentrating on the patient's sense of sight and limit diversions that involve other senses
- C. Staying outside of the patient's field of vision when performing personal hygiene for them
- D. Cueing the patient when the conversation has ended and when leaving the room
Correct Answer: D
Rationale: When caring for a patient who has a visual deficit, the nurse should indicate when the conversation is over and when they are leaving the room to prevent confusion and promote safety.
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.