Nokea
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.
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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 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.
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.
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 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.