117 Rle 3m Merged

NURS 3230 Chapter 43 Sensory Functioning NCLEX
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1. The plan of care for a client exhibit- Answer:

ing signs of sensory deprivation in- a. Providing a back rub with morning
cludes incorporating tactile stimula- and evening care.
tion. Which nursing intervention will
provide tactile simulation? Rationale:
Tactile stimulation includes back
a. Providing a back rub with morning rubs, foot soaks, turning and reposi-
and evening care. tioning, passive range-of-motion ex-
b. Delivering meticulous oral care. ercises, hugs, and touching. Orient-
c. Orienting the client to his environ- ing a client to his environment is cog-
ment. nitive input. Placing a calendar and
d. Placing a calendar and clock on clock on the client's bedside table is
the client's bedside table. visual stimulation. Oral care is gusta-
tory and olfactory stimulation.
2. The nurse is preparing to reposition Answer:

a confused client from a supine po- d. Rephrase the direction in different
sition to a side-lying position. The terms.
nurse has asked the client to shift
her weight accordingly, but the client Rationale:
has not responded to the nurse's Rephrasing an instruction in sim-
request. How should the nurse re- ple terms may enhance a confused
spond? client's understand. This is preferable
to proceeding in spite of the client.
a. Reposition the client without the Asking for help from a colleague and
client's assistance. asking the client if she feels confused
b. Enlist the assistance of a col- are not likely to enhance communi-
league. cation with the client.
c. Ask the client if she is feeling con-
fused.
d. Rephrase the direction in different
terms.
3. The nurse determines that when a Answer:

female client who underwent a mam- a. Overload
mogram earlier in the day is asked to
have a breast ultrasound, and is in- Rationale:
formed that she demonstrates signs When the reticular activating system
of breast malignancy, the client is at (RAS) is overwhelmed with input,
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risk for experiencing sensory... a person may experience sensory
overload and feel confused, anxious,
a. Overload and unable to take constructive ac-
b. Stimulation tion.
c. Adaptation
d. Deprivation
4. During the nurse's morning assess- Answer:

ment of a client with a diagnosis of c. Reorient the client to place and
dementia, the client states that the time.
year is 1949 and she believes she
is in a hotel. How should the nurse Rationale:
best respond to this client's disorien- It is appropriate to reorient clients
tation? who are confused. Doing so in an
effective and empathic manner re-
a. Ask the client what she was doing quires the astute implementation of
in 1949 and what hotel she believes nursing skills. Engaging more deeply
she is in. with the client's incorrect responses
b. Thank the client for her responses does not reorient her. Attempting to
and document her cognitive status. reorient the client in a subtle and in-
c. Reorient the client to place and direct manner is not likely to be ef-
time. fective. Documenting the client's re-
d. Provide hints during conversation sponse is necessary, but this should
as to the correct year and place. be followed up by reorientation.
5. A hospital client has been awakened Answer:

at night by the alarm on his room- d. Reticular activating system (RAS)
mate's intravenous pump. This client Rationale:
was aroused by brain action in his... The RAS is the network that medi-
a. Prefrontal cortex ates arousal.
b. Limbic system
c. Cerebellum
d. Reticular activating system (RAS)
6. The nurse is assessing a neglect- Answer:

ed child brought to the emergency a. Sensory deprivation
department. The grandmother of the
child reports that the child remains in Rationale:
the crib and is removed from the crib Sensory deprivation results when a
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only when the child is fed. During the person experiences decreased sen-
time in the crib, what is the child most sory input or input that is monot-
likely to have experienced? onous, unpatterned, or meaning-
less. Kinesthesia refers to aware-
a. Sensory deprivation ness of positioning of body parts and
b. Kinesthesia body movement. Stereognosis is the
c. Stereognosis sense that perceives the solidity of
d. Adaption objects and their size, shape, and
texture. Adaption occurs when the
body quickly adapts to constant stim-
uli.
7. A nursing instructor is speaking to Answer:

a group of nursing student about b. Demonstrating or pantomiming
proper care of the ears to promote ideas to clients with hearing impair-
hearing, as well as techniques to fol- ments.
low when working with clients with Rationale:
hearing impairments. An appropri- For hearing-impaired clients, demon-
ate nursing intervention discussed strating or pantomiming may as-
by the instructor includes which of sist in communication. Clients should
the following? be instructed to avoid cleaning the
a. Speaking loudly and directly to ear with cotton-tipped applicators or
clients with hearing impairments. sharp objects. While speaking di-
b. Demonstrating or pantomiming rectly may enhance communication,
ideas to clients with hearing impair- speaking loudly will not benefit the
ments. client. Clients should be discouraged
c. Encouraging clients to use ear- from using earphones that concen-
phones adjusted to a loud volume for trate loud noise in the ear canal.
hearing.
d. Cleaning the clients' ears daily with
a cotton-tipped applicator.
8. A nurse explains to a client what he Answer:

will typically see, hear, and feel dur- c. Sensation identification
ing his scheduled surgery. The nurse
is engaged in which of the following? Rationale:
The nurse is implementing pro-
a. Dysfunction identification cedure preparation to prevent
b. Outcome identification over-stimulation of the client before
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c. Sensation identification the surgery. More specifically, the
d. Stimulation identification nurse is using sensation informa-
tion which involves objectively and
specifically describing to the client, in
serial order, what he or she typically
will see, hear, smell, taste, or feel
(tactile) in a particular situation (rare
or atypical events are not to be in-
cluded). Outcome identification is the
establishment of goals and outcome
criteria to achieve optimal sensory
function. Dysfunction identification is
an assessment method used to iden-
tify actual sensory loss. Stimulation
reduction is a nursing intervention for
altered sensory perception function,
which involves reducing the amount
of stimulation provided to the client to
promote sensory perception.
9. Which of the following situations Answer:

demonstrates sensory adaptation? c. A client has learned to sleep
through the frequent beeping of her
a. A client with vision loss has begun intravenous pump.
buying large-print books.
b. A client with hearing loss has Rationale:
learned to communicate using sign Adaptation occurs when the body
language. adapts to constant stimuli, such as
c. A client has learned to sleep the continuous beeping of a hospi-
through the frequent beeping of her tal device. Adaption is not the same
intravenous pump. as the compensation in routines or
d. A client believes his hearing has other sense that occurs when clients
come more acute since he lost his experience sensory losses.
vision.
10. A special needs child has been Answer:

placed in a classroom with other spe- a. Sensory overload
cial needs children. The classroom is
noisy with a high level of activity, and Rationale:
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the child appears to have difficulty Sensory overload is the condition
concentrating on his work. What is that results when a person experi-
the child likely experiencing? ences so much sensory stimuli that
the brain is unable to either respond
a. Sensory overload meaningfully or ignore the stimuli.
b. Sensory reception Sensory deprivation results when a
c. Sensory perception person experiences decreased sen-
d. Sensory deprivation sory input. Sensory perception is the
conscious process of selecting, or-
ganizing, and interpreting data from
the senses. Sensory reception is the
process of receiving data about the
internal and external environment
through the senses.
11. A hospitalized client who refuses Answer:

to eat because she fears that the a. Delusions
kitchen personnel are poisoning her
food is experiencing what? Rationale:
Delusions, beliefs not based in real-
a. Delusions ity, reflect an unconscious need or
b. Agoraphobia fear.
c. Anorexia
d. Hallucinations
12. Which of the following clients is most Answer:

likely susceptible to the effects of d. A client who is receiving care in
disturbed sensory perception? the intensive care unit (ICU) for the
treatment of septic shock.
a. A client who is having cataract
surgery in an outpatient eye clinic. Rationale:
b. A client who has just been ad- Clients in critical care settings are
mitted to the emergency department particularly susceptible to severe
with complaints of chest pain. sensory alterations. A client who
c. An older adult client whose lung has been in a setting for a short
disease is being treated in the acute time, such as an emergency or day
care for elders (ACE) unit of the hos- surgery setting, is less likely to expe-
pital. rience disturbed sensory perception.
d. A client who is receiving care in Older adults are often vulnerable to
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the intensive care unit (ICU) for the sensory disturbances, but the risks
treatment of septic shock. posed by an ICU setting likely super-
sede a geriatric medical unit.
13. A child 4 years of age has a moth- Answer:

er who is employed and works for d. Impaired Parenting associated
home. To accomplish her daily work, with failure to provide stimuli for
she allows the child to watch tele- growth.
vision for six to eight hours a day.
Based upon this information, what Rationale:
nursing diagnosis would be applica- Based upon lack of stimuli (sensory
ble to this family? deprivation), an appropriate nursing
diagnosis is Impaired Parenting as-
a. Deficient Diversional Activity relat- sociated with failure to provide stim-
ed to impaired senses. uli for growth. There is no informa-
b. Disturbed Thought Processes re- tion that states the child has im-
lated to sensory overload. paired senses, sensory overload, or
c. Impaired Skin Integrity related to impaired skin integrity.
absent tactile sensation.
d. Impaired Parenting associated
with failure to provide stimuli for
growth.
14. A client returning from the oper- Answer:

ating room is unconscious. What d. Talk to the client in a normal tone
guidelines should the nurse consid- of voice.
er when communicating with this
client? Rationale:
Assume the person can hear you, so
a. Provide loud environmental stimuli be careful of what is said in the per-
to assist in arousing the client. son's presence, and speak in a nor-
b. Gently shake the client's hand or mal tone of voice. Speak to the per-
arm before speaking to him or her. son before touching because touch
c. There are no guidelines to consider is an effective means of communica-
because the client cannot hear the tion.
nurse.
d. Talk to the client in a normal tone
of voice.
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15. A neonatal intensive care nurse is Answer:
caring for an infant born premature- c. Limit lighting, visual, and vestibular
ly. How will the nurse manage the stimulation.
infant's environment to best support
his sensory needs? Rationale:
To facilitate developmentally sup-
a. Provide an active, stimulating envi- portive care, it is recommended that
ronment. medically fragile infants have limited
b. Encourage frequent visitors and light, visual, and vestibular stimula-
tactile stimulation at least hourly. tion to simulate being in the womb.
c. Limit lighting, visual, and vestibu-
lar stimulation.
d. Provide changing patterns of light
and shade, and the use of bright ob-
jects.
16. An older adult client who is in a Answer:

long-term care facility tells the nurse, d. Delusion
"I'm not eating that, it's poisoned."
The nurse interprets this as which Rationale:
manifestation of altered sensory per- The client is exhibiting delusional
ception? behavior. Delusions are beliefs not
based in reality that reflect an un-
a. Sensory deficit conscious need or fear. Hallucina-
b. Hallucination tions are sensory impressions, such
c. Withdrawal as hearing voices, based on inter-
d. Delusion nal stimulation. Sensory deficit is im-
paired function in sensory reception
or perception. Withdrawal is charac-
terized by loss of interest in activities
or interaction with others.
17. A client has expressed great relief at Answer:

the improvement in her hearing after d. Sensory reception
irrigation of her ear canal yielded a
large amount of impacted cerumen Rationale:
(wax). This client was experiencing a Impacted cerumen is an example of
sensory alteration related to which of a sensory disturbance that is rooted
the following? in interference with the client's recep-
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tion of stimuli. In this case, sound
a. Sensory reaction is unable to stimulate the organs of
b. Sensory perception hearing and the client does not have
c. Sensory transmission a deficit in the perception, transmis-
d. Sensory reception sion, or reaction to sound.
18. A cycling accident has resulted in Answer:

a head injury to a male client and c. Disturbed Sensory Perception:
he has been admitted to the inten- Sensory Deprivation
sive care unit for the treatment of
increased intracranial pressure. Con- Rationale:
sequently, he has been placed in a A care environment that is deliber-
private room with low light and his ately organized to minimize stimula-
care has been organized to minimize tion creates a risk of sensory depri-
disturbances. What nursing diagno- vation.
sis is this client as risk of?
a. Acute Confusion
b. Disturbed Sensory Perception:
Sensory Overload
c. Disturbed Sensory Perception:
Sensory Deprivation
d. Chronic Confusion
19. A resident of a long-term care facili- Answer:

ty has moderate hearing loss. When a. Minimize background noises and
communicating with this resident, ensure that lighting is adequate to
what should the nurse do? see the nurse's face.
a. Minimize background noises and Rationale:

ensure that lighting is adequate to When communicating with clients
see the nurse's face. who have hearing loss, it is impor-
b. Use written communication when- tant for the nurse to minimize back-
ever possible in order to minimize Mr. ground noise and to position him-
Fields' frustration. self or herself where there is enough
c. Use vocabulary and concepts that light in oder to facilitate lip reading.
are as simple and unambiguous as It would be unnecessary and inap-
possible. propriate to exclusively use written
d. Repeat each direction or question communication with a client who has
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in different terms in order to maxi- moderate hearing loss, and to repeat
mize understanding. all questions and instructions in dif-
ferent terms. A hearing deficit is not
synonymous with a cognitive deficit;
consequently, it is not usually neces-
sary to simplify concepts or vocabu-
lary.
20. Which of the following clients is ex- Answer:

periencing a disturbance in sensory c. A client who is experiencing acute
perception as the primary problem, confusion as a result of a drug inter-
rather than the etiology of another action.
problem?
Rationale:
a. A client who is experiencing pow- Acute confusion is a nursing diag-
erlessness as a result of his inability nosis that is a direct example of a
to interact with his environment. disturbance in sensory perception.
b. A client who is experiencing sleep Sleep disturbances, powerlessness,
disturbances as a result of sensory and ineffective coping are nursing di-
deprivation. agnoses that may result from alter-
c. A client who is experiencing acute ations in sensory perception.
confusion as a result of a drug inter-
action.
d. A client who is exhibiting ineffec-
tive coping related to sensory over-
load.
21. A client brought to the emergency Answer:

room is unconscious and cannot be c. Coma
aroused. The client is breathing and
has a heartbeat. What state of aware- Rationale:
ness is this client exhibiting? Unconscious states include asleep,
stupor, and coma. Coma is charac-
a. Asleep terized by an inability to be aroused
b. Somnolence and no response to stimuli. A client in
c. Coma a stupor can be aroused by extreme
d. Stupor and/or repeated stimuli.
22.
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A nursing instructor is preparing Answer:
a class presentation about senso- a. Young adult
ry perception across the lifespan.
At which developmental stage would Rationale:
the instructor describe sensory per- A young adult's sensory perception
ception as at its peak? function is at is peak. However, as
people reach middle age, the be-
a. Young adult gin to notice certain changes in their
b. Older adult sensory system. Eyesight diminish-
c. Adolescent es, sounds become more muffled,
d. Preschooler and the other sensory systems de-
teriorate. Preschoolers are in the
process of building their sensory per-
ception skills by investigating and
learning about the environment. Sen-
sory perception in an adolescent is
still in the process of development.
At this developmental stage, ado-
lescents are learning to make inde-
pendent responses based on what
is perceived through the senses. As
people reach older adulthood, sen-
sory systems deteriorate and senso-
ry perception is weak.
23. A client informs the nurse that she is Answer:

not able to recall her phone number a. Impaired memory
or address, and this is disconcert-
ing. The nurse recognizes that the Rationale:
inability to recall information is in- Impaired memory is a state in which
dicative of which sensory/perception an individual experiences the in-
problem? ability to remember or recall bits
of information or behavioral skills.
a. Impaired memory Disturbed sensory perception is a
b. Acute confusion state in which the individual expe-
c. Chronic confusion riences a change in the amount,
d. Disturbed sensory perception pattern, or interpretation of incom-
ing stimuli. Acute confusion is the
abrupt onset of a closet of global,
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transient changes and disturbances
in attention, cognition, psychomotor
activity level of consciousness, or
sleep-wake cycle. Chronic confusion
is an irreversible, long-standing, or
progressive deterioration of intellect
and personality, characterized by de-
creased ability to interpret environ-
ment stimuli or decreased capacity
for intellectual thought.
24. A nurse in a family clinic asks a client, Answer:

"How do you spend a typical day?" b. Normal patten identification
The nurse is collecting information
about which of the following? Rationale:
The nurse asking the client a gener-
a. Outcome identification al question to determine his or her
b. Normal patten identification normal pattern of sensory percep-
c. Dysfunction identification tion is using normal pattern identifi-
d. Risk identification cation. Dysfunction identification in-
volves the collection of data about
actual sensory perception problems.
Risk identification involves eliciting
information about factors that may
place the client at increased risk
of sensory perception dysfunction.
Goals for achieving optimal sensory
function are determined during out-
come identification.
25. To meet the learning needs of the Answer:

older adult, the nurse incorporates d. Allowing more time for the pro-
which of the following considera- cessing of the information.
tions in planning to teach a client
with diabetes age 73 years about in- Rationale:
sulin administration? As a person approached 60 to 70
years of age, marked decrements in
a. Demonstrating a wide variety of sensory/perceptual behaviors begin.
syringes and techniques. This reduction in efficiency means
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b. Requesting hearing aids to help that older people cannot process
the client receive information. sensory input as rapidly as they did
c. Using numerous handouts and de- when they were young.
tailed education plan.
d. Allowing more time for the pro-
cessing of the information.
26. Baby J is a premature infant born 6 Answer:

weeks early, living in the NICU. She d. All of the above
is restless, crying frequently, which
drops her oxygen saturation, despite Rationale:
being on oxygen supplementation. Sensory deprivation
Which does she have? -not in normal (uterus) environment
a. Sensory deprivation Sensory overload

b. Sensory overload -machines, touch, constant care
c. Sensory deficit
d. All of the above Sensory deficit
-developmental
-enforced: tape over eyes for protec-
tion, etc.
27. You enter Mrs. Angelo's room on the Answer:

surgical unit for the first time. She is d. Hearing loss
a 60 year old woman scheduled for
gallbladder surgery today. You plan Rationale:
to complete some preop teaching. (Knowing/Assuming) Mrs. Angelo
You knock, but don't get any answer, does not show other signs of a cogni-
so you enter. She watches you intent- tive deficit, so it would be appropriate
ly, looks worried, but is nodding and to assume that she is experiencing
smiling. You ask if she has any ques- hearing loss.
tions about her surgery, and she an-
swers: "Yes dear!" smiling, but does
not ask a question. What is going on?
a. Mild dementia
b. Anxiety
c. Delirium
d. Hearing loss
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28. When are you legally blind? Answer:
b. Corrected vision in better eye is
a. No perception of light in either eye 20/200 or worse
b. Corrected vision in better eye is
20/200 or worse Rationale:
c. Light perceived, but cannot distin- This is the definition for being legally
guish forms blind.
d. You don't really understand the law
29. Mr. Sweet, patient known to you due Answer:

to his experience with DKA, comes c. Retinal detachment - due to DM -
to your ER complaining of light flash- ER opthamologist, surgery
es in his right eye after coughing
and sneezing due to a cold. He has Rationale:
no pain, but says a curtain is clos- Mr. Sweet is showing S/S of retinopa-
ing over his lower right visual field. thy, due to his diabetes mellitus. This
What's happening? Why? What do is an emergent situation that requires
you do? immediate attention.
a. Eye trauma - due to fall - stabilize,

call 911
b. Keratitis - due to infection with
cold - patch, antibiotics
c. Retinal detachment - due to DM -
ER opthamologist, surgery
d. Acute angle-closure glaucoma -
coughing - rest, dark, miotics, hyper-
osmotic agents, surgery
30. A nurse who is assessing an older fe- Answer:

male patient in a long-term care facil- b. Provide interaction with children
ity notes that the patient is at risk for and pets.
sensory deprivation related to severe d. Ensure that the patient shares
rheumatoid arthritis limiting her ac- meals with other patients.
tivity. Which interventions would the e. Discourage the use of sedatives.
nurse recommend based on this find-
ing? Select all that apply. Rationale:
For a patient who has sensory depri-
a. Use a lower tone when communi- vation, the nurse should provide in-
13 / 20
cating with the patient. teraction with children and pets, en-
b. Provide interaction with children sure that the patient shares meals
and pets. with other patients, and discourage
c. Decrease environmental noise. the use of sedatives. Using a low-
d. Ensure that the patient shares er tone of voice is appropriate for
meals with other patients. a patient who has a hearing deficit,
e. Discourage the use of sedatives. decreasing environmental noise is
f. Provide adequate lighting and clear an intervention for sensory overload,
pathways of clutter. and providing adequate lighting and
removing clutter is an intervention for
a vision deficit.
31. A nurse is assessing a 78-year-old Answer:

male patient for kinesthetic and c. The nurse asks the patient if he
visceral disturbances. Which tech- noticed any changes in the way he
niques would the nurse use for this perceives his body.
assessment? Select all that apply. e. The nurse notes if the patient with-
draws from being touched.
a. The nurse asks the patient if he is f. The nurse notes if the patient
bored, and if so, why. seems unsure of his body parts
b. The nurse asks the patient if any- and/or position.
thing interferes with the functioning
of his senses. Rationale:
c. The nurse asks the patient if he To assess for kinesthetic and vis-
noticed any changes in the way he ceral disturbances, the nurse would
perceives his body. assess for perceived body changes
d. The nurse asks the patient if he inside and out, and changes in body
has found it difficult to communicate parts or position. Asking if the pa-
verbally. tient is bored assesses stimulation,
e. The nurse notes if the patient with- asking if anything interferes with his
draws from being touched. senses assesses reception, and ask-
f. The nurse notes if the patient ing about difficulty communicating
seems unsure of his body parts assesses for transmission-percep-
and/or position. tion-reaction.
32. A nurse asks a patient to close her Answer:

eyes, state when she feels some- c. Tactile
thing, and describe the feeling. The
nurse then brushes the patient's skin Rationale:
14 / 20
with a cotton ball, and touches the The nurse is assessing for tactile
patient's skin with both sides of a (touch) disturbances by brushing the
safety pin. Which sense is the nurse skin with a cotton ball and touching
assessing? the skin with a safety pin. Gustato-
ry disturbances involve taste, olfacto-
a. Gustatory ry disturbances involve the sense of
b. Olfactory smell, and kinesthetic disturbances
c. Tactile are related to body positioning.
d. Kinesthetic
33. A nurse observes that a patient who Answer:

has cataracts is sitting closer to b. Sensory reception
the television than usual. The nurse Rationale:
would interpret that the etiologic ba- Cataracts are interfering with the pa-
sis of this sensory problem is an al- tient's ability to receive visual stim-
teration in: uli: altered sensory reception. The
a. Environmental stimuli nature of incoming stimuli, the con-
b. Sensory reception duction of nerve impulses, and the
c. Nerve impulse conduction translation of incoming impulses in
d. Impulse translation the brain are not a problem here.
34. Which action would be most impor- Answer:

tant for a nurse to include in the plan b. Speaking distinctly, using lower
of care for a patient who is 85 years frequencies
old and has presbycusis?
Rationale:
a. Obtaining large-print written mate- Presbycusis is a normal loss of hear-
rial ing as a result of the aging process.
b. Speaking distinctly, using lower Speaking distinctly in lower frequen-
frequencies cies is indicated. The other choices
c. Decreasing tactile stimulation refer to interventions for other senso-
d. Initiating a safety program to pre- ry problems.
vent falls
35. A patient is in the late stages of AIDS, Answer:

which is affecting his brain as well d. Emotional responses
as other major organ systems. The Rationale:
patient confides to the nurse that Emotional responses are an effect
he feels terribly alone because most of sensory deprivation, and although
15 / 20
of his friends are afraid to visit. The they may be occurring with this pa-
nurse determines that the least likely tient they are not the underlying eti-
underlying etiology for his sensory ology for his condition. This patient
problems would be: is receiving decreased environmen-
a. Stimulation tal stimuli (a) (ex: from his friends), is
b. Reception more than likely experiencing prob-
c. Transmission-perception-reaction lems with reception because of ma-
d. Emotional responses jor organ involvement (b), and his
impaired brain function will impair im-
pulse transmission-perception-reac-
tion (c).
36. Which patient would a nurse assess Answer:

as being at greatest risk for sensory a. An older man confined to bed at
deprivation? home after a stroke
a. An older man confined to bed at Rationale:

home after a stroke The patient confined to bed at home
b. An adolescent in an oncology unit is a risk for greatly reduced environ-
working on homework supplied by mental stimuli. All of the other pa-
friends tients are in environments in which
c. A woman in labor environmental stimuli are at least ad-
d. A toddler in a playroom awaiting equate.
same-day surgery
37. A patient in an intensive care burn Answer:

unit for 1 week is in pain much of d. Both sensory deprivation and
the time and has his face and both overload
arms heavily bandaged. His wife vis- Rationale:
its every evening for 15 minutes at 6, This patient's bandages may result in
7, and 8 PM. A heart monitor beeps deficient sensory stimulation (senso-
for a patient on one side, and anoth- ry deprivation), and the monitors and
er patient moans frequently. Assess- other sounds in the intensive care
ment would suggest that the patient burn unit may cause a sensory over-
probably is experiencing: load. All other options are incomplete
a. Sufficient sensory stimulation responses.
b. Deficient sensory stimulation
c. Excessive sensory stimulation
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d. Both sensory deprivation and
overload
38. A patient's spinal cord was severed, Answer:

and he is paralyzed from the waist a. Transmission of tactile stimuli
down. When obtaining data about
this patient, which component of the Rationale:
sensory experience would be most Below-the-waist paralysis makes the
important for the nurse to assess? transmission of tactile stimuli a prob-
lem. Although the other options may
a. Transmission of tactile stimuli be assessed, they are indirectly re-
b. Adequate stimulation in the envi- lated to his paralysis and of lesser
ronment importance at this time.
c. Reception of visual and auditory
stimuli
d. General orientation and ability to
follow commands
39. A nurse is diagnosing an 11-year-old Answer:

6th grade student following a physi- b. Ineffective Role Performance (Stu-
cal assessment. The nurse notes that dent) related to visual impairment
the student's grades have dropped,
she has difficulty completing her Rationale:
work on time, and she frequently An important role for an 11-year-old
rubs her eyes and squints. Her vi- is that of student. Her impaired vision
sual acuity on a Snellen's eye chart is clearly disturbing her role perfor-
is 160/20. Which nursing diagnosis mance as a student, as evidenced by
would be most appropriate? her lower grades. Although the other
options may also represent accurate
a. Deficient Knowledge related to vi- diagnoses for this patient, they do not
sual impairment flow from the data presented.
b. Ineffective Role Performance (Stu-
dent) related to visual impairment
c. Disturbed Body Image related to
visual impairment
d. Delayed Growth and Development
related to visual impairment
40.
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A nurse is caring for a male patient Answer:
with a severe hearing deficit who is c. Provide daily opportunity for him to
able to read lips and use sign lan- participate in a social hour with six to
guage. Which nursing intervention eight people.
would be best to prevent sensory al-
terations for this patient? Rationale:
Although all the options listed are ap-
a. Turn the radio or television volume propriate, providing daily opportuni-
up very loud and close the door to his ties for this patient to participate in
room. a social hour builds on his strength
b. Prevent embarrassment and emo- of being able to lip-read and pro-
tional discomfort as much as possi- vides sufficient sensory stimulation
ble. to prevent sensory deprivation re-
c. Provide daily opportunity for him sulting from his hearing loss, thereby
to participate in a social hour with six meeting his needs.
to eight people.
d. Encourage daily participation in
exercise and physical activity.
41. In a group home in which most pa- Answer:

tients have slight to moderate visual a. Maintaining safety and preventing
or hearing impairment and some are sensory deterioration
periodically confused, what would be
a nurse's first priority in caring for Rationale:
sensory concerns? Safety is a basic physiologic need
that must be met before higher-lev-
a. Maintaining safety and preventing el needs--such as love and belong-
sensory deterioration ing, self-esteem, and self-actualiza-
b. Insisting that every patient partici- tion--can be met.
pate in as many self-care activities as
possible
c. Emphasizing and reinforcing indi-
vidual patient strengths
d. Encouraging reminiscence and life
review in groups
42. A nurse formulated the following Answer:

nursing diagnosis for an 8-month-old c. The infant's sensory deprivation is
infant: Disturbed Sensory Percep- still severe.
18 / 20
tion: Sensory Deprivation related to
inadequate parenting.Since that di- Rationale:
agnosis was made, both parents Although the data show that the par-
have attended parenting classes. ents have been motivated to improve
However, both parents works while their parenting skills, it is clear from
the infant stays with her 86-year-old the data that the infant's sensory de-
grandmother, who has reduced vi- privation is still severe. The data sug-
sion. The parents provide appropri- gest that the grandmother is not im-
ate stimulation in the evening. At an proving the infant's care, but there is
evaluation conference at the age of nothing to suggest that she is unable
11 months, the infant lies on the floor to do so if shown how.
sucking her thumb and rocking her
body. Her facial expression is dull,
and she vocalizes only in a low mo-
notone ("uh-h-h"). Which statement
accurately reflects evaluation about
the child's sensory deprivation?
a. The infant's parents lack motiva-

tion to provide necessary stimula-
tion.
b. The grandmother is unable to im-
prove the infant's care.
c. The infant's sensory deprivation is
still severe.
d. This is normal behavior for an
11-month-old infant.
43. A nurse formulates the following di- Answer:

agnosis for an older female patient c. Orient the patient to time, place,
in a long-term care facility: Disturbed and person frequently.
Sensory Perception: Chronic Senso- d. Provide daily contact with children,
ry Deprivation related to the effects community people, and pets.
of aging. The patient walked out the f. Provide a radio and television in the
door unobserved and was lost for patient's room.
several hours. Which interventions
would be most effective for this pa- Rationale:
tient? Select all that apply. Even if well motivated, ignoring a pa-
tient's confusion to prevent embar-
19 / 20
a. Ignore when the patient is con- rassment may be dangerous, as it
fused or go along to prevent embar- was in this case in which the appro-
rassment. priate safety precautions were never
b. Reduce the number and type of implemented. Reducing the type of
stimuli in the patient's room. stimuli in the room and decreasing
c. Orient the patient to time, place, environmental noise is appropriate
and person frequently. for a patient who is experiencing sen-
d. Provide daily contact with children, sory overload. The other options are
community people, and pets. related to sensory deprivation and
e. Decrease background or loud nois- are appropriate for this patient.
es in the environment.
f. Provide a radio and television in the
patient's room.
44. An older female patient has a se- Answer:

vere visual deficit related to glauco- d. Indicate to the patient when the
ma. Which nursing action would be conversation has ended and when
appropriate when providing care for the nurse is leaving the room.
this patient?
Rationale:
a. Assist the patient to ambulate by When caring for a patient who has
walking slightly behind the person a visual deficit, the nurse should
and grasping the patient's arm. indicate when the conversation is
b. Concentrate on the sense of sight over and when he or she is leaving
and limit diversions that involve oth- the room, assist with ambulation by
er senses. walking slightly ahead of the person
c. Stay outside of the patient's field and allowing her to grasp the nurse's
of vision when performing personal arm, provide diversions using other
hygiene for the patient. senses, and stay in the person's field
d. Indicate to the patient when the of vision if she has partial or reduced
conversation has ended and when peripheral vision.
the nurse is leaving the room.
20 / 20
NCLEX Q&A Sensory
Study online at https://quizlet.com/_1pdusm
1. The nurse assessing a neglected child C: sensory deprivation

brought into the emergency department rationale
the grandmother of the child reports that sensory deprivation results in a
the child remains in the crib and nre- person experiences decreased
moved only when the child is fed. During sensory input or input that
the time in the crib, what is the child most is monotonous, unpatterend, or
likely to have experienced? meaningless. Kinethesia refers
to awareness of positioning of
A -adaptation body parts in body movement.
B- stereognosis Stereognosis is the sense that
C- sensory deprivation precieves the solidity of objects
D- Kinesthesia and their size, shape, and tex-
ture. Adaptation occurs when the
body quickly adapts to constant
stimuli.
2. The patient brought to the emergency C: Coma

room is unconscious and cannot be unconscious states includes a
aroused. The patient is breathing and sleep, stupor, and coma. Coma
has a heartbeat. What state of awareness Is characterized by an inability to
is the patient exhibiting? be aroused and no response to
stimuli. A patient in a stupor can
A- Stupor be aroused by extreme and /or
B- Somnolence repeated stimuli.
C- Coma
D- asleep
3. A special needs child has been placed D: sensory overload

in a classroom with other special needs rationale
children. The classroom is noisy with a sensory overload is the condition
high level of activity, and the child ap- that results when a person ex-
pears to have difficulty concentrating on periences so much sensory stim-
his work. What is the child's likely expe- uli that the brain is unable to ei-
riencing? ther respond meaningfully or ig-
nore the stimuli. Sensory depri-
A- sensory deprivation vation results when a person ex-
B- sensory reception periences decreased sensory in-
C- sensory perception put. Sensory perception is the
D- sensory overload conscious process of selecting,
1/9
NCLEX Q&A Sensory
organizing, and interpreting data
from the senses. Sensory recep-
tion is the process of receiving
data about the environment in-
ternal and external senses.
4. A nursing instructor is speaking to a D: demonstrating or pantomim-

group of students about proper care of ing ideas to patients with hearing
the ears to promote hearing and tech- impairments
niques to follow when working with pa- rationale
tients with hearing impairments. An ap- For hearing impaired patient,
propriate nursing intervention best by demonstrating on pantomiming
the instructor includes which of the fol- may assist in communication.
lowing? Patients should be instructed to
avoid cleaning the ear with cot-
A: cleaning the patient's ears daily with a ton tipped applicator's or sharp
cotton tipped applicator. object. While speaking direct-
B: speaking loudly and directly to pa- ly may enhance communication,
tients with hearing impairment speaking loudly will not bene-
C: encouraging patients to use ear- fit the patient. Patients should
phones adjusted to a loud volume for be discouraged from using ear-
hearing. phones that concentrate loud
D: demonstrating or pantomiming ideas noise and ear canal.
to patients with hearing impairment
5. A patient returning from operating room B: talk to the patient in a normal

is unconscious. What guidelines should tone of voice
the nurse consider when communicating rationale
with this patient? Assume the person can hear
you, so be careful of what is
A: provide loud environmental stimuli to said in the person's presence
assist in arousing the patient. and speak in a normal tone of
B: talk to the patient in a normal tone of voice. Speak to the person be-
voice. fore touching because touch is
C: gently shake the patient's hand or arm an effective means of communi-
before speaking to him or her. cation.
D: there are no guidelines to consider be-
cause the patient cannot hear the nurse
2/9
NCLEX Q&A Sensory
6. A neonatal intensive care nurse is car- B: limit lighting, visual, and
ing for an infant born prematurely. How vestibular stimulation
will the nurse manage the infants en- rationale
vironment to best support the sensory to facilitate developmentally sup-
needs? portive care, it is recommend-
ed that medically fragile infants
A: provide an active, stimulating environ- have limited light, visual, and
ment. vestibular stimulation to simulate
B: limit lighting, visual, and vestibular being in the womb.
stimulation
C: provide changing patterns of light and
shade and use of bright objects.
D: encourage frequent visitors and tac-
tile stimulation at least hourly
7. The plan of care for a patient exhibiting C: providing a back rub with
signs of sensory deprivation includes morning and evening care
incorporating tactile stimulation. Which rationale
nursing intervention will provide tactile tactile stimulation includes back
stimulation? rubs, foot soaks, turning and
repositioning, passive range of
A: placing a calendar and clock on the motion exercises, hugs, and
patient's bedside table touching. Orientating the patient
B: delivering meticulous oral care to his environment is cognitive in-
C: providing a back rub with morning and put. Placing a calendar and clock
evening care on the patient's bedside tables
D: orientating the patient is environment is visual stimulation. Oral care is
gustatory and olfactory stimula-
tion.
8. The nurses assessing a patient's gus- B: tell me at the taste on your

tatory function. What approach by the tongue is sweet, sour, bitter, or
nurse will assist in assessing this sensa-
salty.
tion? Rationale
Gustatory sensations equate
A: close your eyes and tell me what you to taste. Repeating word that
smell the auditory function. Reading
B tell me if the taste on your tongue is Assesses visual disturbances.
sweet, sour, bitter, or salty
3/9
NCLEX Q&A Sensory
C. repeat the words that I speak softly to Smelling assesses for olfactory
you disturbances.
D. please read this paragraph to me
9. The patient informs nurse that she is not A: impaired memory

able to recall her phone number or her rationale
address, and this is concerning to the impaired memory of the state
patient. Nurse recognizes the inability to in which the individual experi-
recall information is indicative of what ences an inability to remember
sensory/ perception problem? or recall bits of information or
behavioral skills. Disturbed sen-
A: impaired memory sory perception is a state in
B: acute confusion which the individual experiences
C: disrupted sensory perception a change in the amount, pat-
D: chronic confusion terns, or interpretation of incom-
ing stimuli. Acute confusion is the
abrupt onset of a cluster or glob-
al, transient changes and dis-
turbances in attention, cognition,
psychomotor activity level of con-
sciousness, or sleep wake cy-
cle. Chronic confusion is an ir-
reversible, long-standing, or pro-
gressive deterioration of intellect
and personality characterized by
decreased ability to interpret en-
vironmental stimuli or decreased
capacity for intellectual thought.
10. A four-year-old child has a mother who isB: impaired parenting associated
employed and works from home. To ac- with failure to provide stimuli for
complish her daily work, she allows the growth
child's watch television for 6 to 8 hoursrationale
a day. Based on this information what based upon lack of stimuli (sen-
nursing diagnosis would be applicable sory deprivation), an appropri-
to this family? ate nursing diagnosis is impaired
parenting associate with failure
A: impaired skin integrity related to ac- to provide stimuli for growth.
cept tactile sensation There is no information that the
4/9
NCLEX Q&A Sensory
B: impaired parenting associated with child has impaired senses, sen-
failure to provide stimuli for growth sory overload, or impaired skin
C: deficient diversional activities related integrity.
to impaired senses
D: disturbed thought process related to
sensory overload
11. The hospital patient has been awak- A: reticular activating system
ened at night by the alarm on his room- RAS
mates intravenous pump. This patient Rationale
was aroused by brain action in his: the RAS is the network that me-
diate arousal.
A: reticular activating system (RAS)
B: limbic system
C: prefrontal cortex
D: cerebellum
12. Which of the following patient most likely D: a patient receiving care in the
susceptible to the effects of disturbed intensive care unit (ICU) for the
sensory perception? treatment of septic shock
rationale
A: a patient who has just been admitted Patient in critical care settings
to the emergency department with com- are particularly susceptible se-
plaints of chest pain. vere sensory alteration. A pa-
B: an older adult patient whose lung dis- tient who has been in a setting
eases being treated in acute care for el- for a short time, such as emer-
ders (ACE) unit of the hospital. gency or day surgery setting,
C: a patient is having cataract surgery in is less likely to experience dis-
an outpatient eye clinic. turbed sensory perception. Old-
D: a patient is receiving care in the in- er adults are often vulnerable
tensive care unit ICU for the treatment of to sensory disturbances, but the
septic shock. risk posed by an ICU setting like-
ly superspeede a geriatric med-
ical unit.
13. A nurse who provides care in a long term All the above.
setting is aware of the need to protect Adequate lighting is an important
sensory stimulation for the president. environmental modification that
What interventions should the nurse helps to accommodate age-re-
5/9
NCLEX Q&A Sensory
choose in order to achieve this goal? lated vision losses. Assessing
Select all that apply. residents sensory function,reori-
entating residents, ensuring the
A: regularly assess residents were age use of appropriate assistive de-
related sensory losses vices, and assesses for the ef-
B: maintaining low light environment to fects of drugs are all nursing
preclude sensory overload actions that can positively im-
C: regularly reorient residents who are pact sensory stimulation for older
disorientated to person, place, or time. adults.
D: ensure that residents who require as-
sistive devices are regularly using them.
E: assess residents for the CNS of drugs
and potential polypharmacy.
14. Which of the following patients is experi- B: a patient who is experiencing

encing a disturbance in sensory percep- acute confusion as a result of a
tion as the primary problem rather than drug interaction
the etiology of another problem? rationale
acute confusion is a nursing di-
A: A patient is experiencing powerless- agnoses that is a direct exam-
ness as a result of his inability to interact ple of a disturbance in sensory
with his environment. perception. Sleep disturbances,
B. A patient who is experiencing acute powerlessness, and ineffective
confusion as a result of a drug interac- coping are nursing diagnosis that
tion. may result from alterations in
C. The patient was exhibiting ineffective sensory perception.
coping related to sensory overload.
D: a patient who is experiencing sleep
disturbances as a result of sensory de-
pravation.
15. A cycling accident has resulted in a head A: Disturbed sensory perception;

injury to a male patient and he has been sensory deprivation
admitted to the intensive care unit for rationale
the treatment of increased intra-cranial A care environment that is de-
pressure. Consequentially, he has been liberately organized to minimize
placed in a private room with low light stimulation creates a risk of sen-
and his care has been organized to min- sory deprivation.
imize disturbances. What nursing diag-
6/9
NCLEX Q&A Sensory
noses is this patient at risk of?
A: Disturbed sensory perception; senso-

ry deprivation
B: acute confusion
C: disruptive sensory perception: senso-
ry overload
D: chronic confusion
16. The nurse is repositioned a confused pa- C: rephrase the direction in differ-
tients from a supine position to a side-ly-
ent terms
ing position. The nurse had asked the rationale
patient to shift her weight accordingly, rephrasing and instruction in
but the patient has not responded to the simple terms may enhance a
nurse's request. How should the nurse confused patient's understand-
respond? ing. This is preferable to proceed-
ing in spite of the patient. Ask-
A: reposition the patient without the pa- ing for help from a colleague and
tient's assistance. asking the patient if she feels
B: ask the patient if she is feeling con- confused are not likely to en-
fused. hance communication with the
C: rephrase the direction in different patient.
terms
D: enlist the assistance of a colleague
17. A patient has expressed great relief at C: sensory reception

the improvement in her hearing after ir- rationale
rigation of the ear canal yielding a large Impacted cerumen is an exam-
amount of impacted cerumen. The pa- ple of a sensory disturbance that
tient was experiencing a sensory alter- is rooted in interference with the
ation related to which of the following? patient's reception of stimuli. In
this case, sound is unable to
A: sensory transmission stimulate the organs of hearing
B: sensory perception and the patient does not have
C: sensory reception a deficit in the perception, trans-
D: sensory reaction mission, or reaction to sound.
18. During the nurse's morning assessment B: reorient the patient to place
of the patient with a diagnosis of demen- and time.
7/9
NCLEX Q&A Sensory
tia, the patient states that the year is 1949 Rationale
and she believes she is in a hotel. How it is appropriate to reorient pa-
should the nurse best respond to the tients who are confused. Doing
patient's disorientation? so in an effective and empath-
ic manner requires astute imple-
A: At the patient what she was doing in mentation of nursing skills. En-
1949 and what hotel she believes she is gaging more deeply with the pa-
in. tient's incorrect responses does
B: Reorient the patient to place and time. not reorient her and attempting
C: Provide hints during your conversa- to reorient the patient is a subtle
tion to the correct year & place. and indirect manner is not likely
D: Thanks the patient for her responses to be effective. Documenting the
and document her cognitive status. patient's response is necessary,
but this should be followed up by
reorientation.
19. Mr. Feilds is a resident of a long-term B: minimize background noises

care facility who has moderate hear- and ensure that lighting is ade-
ing loss. When communicating with Mr. quate to the nurses face
Fields what should the nurse do? rationale
when communicating with pa-
A: Use vocabulary and concepts that are tients who have hearing loss, it
as simple and unambiguous as possible. is important for the nurse to min-
B: Minimize background noise and en- imize background noise and to
sure that lighting adequate to see the position himself or herself where
nurses face. there is enough light in order to
C: Repeat each direction or question in facilitate lip reading. It would be
different terms in order to maximize un- unnecessary and inappropriate
derstanding to exclusively use written com-
D: Use written communication whenever munication with a patient who
possible in order to minimize Mr. Fields has moderate hearing loss and
frustration. repeat all questions and instruc-
tions in different terms. A hearing
to that is not synonymous with a
cognitive deficit; consequentially,
it is not usually necessary to sim-
plify concepts or vocabulary.
20.
8/9
NCLEX Q&A Sensory
Which of the following situations demon- D: a patient has learned to sleep
strates sensory adaptation? the frequent beeping of her intra-
venous pump.
A; A patient believes his hearing has be- Rationale
come more acute since he lost his vi- Adaptation occurs when the
sion. body adapts to the constant stim-
B: A patient with vision loss as begun uli, such as the continuous beep-
buying large print books ing of a hospital device. Adap-
C: A patient with hearing loss as learned tation is not the same as the
communicate using sign language compensation in routines or oth-
D: A patient has learned to sleep through er semses that occurs when pa-
the frequent beeping of her intravenous tients experience and sensory
pump. losses.
9/9
Chapter 30: Sensation, Perception & Response NCLEX Questions
Study online at https://quizlet.com/_caohim
1. The nurse checks a patient's ANS: B

pupils using a penlight. Which Photoreceptors located in the retina of the
receptors is the nurse stimu- eyes detect visible light. Proprioceptors in the
lating? skin, muscles,
tendons, ligaments, and joint capsules coor-
a) Chemoreceptors dinate input to enable an individual to sense
b) Photoreceptors the position of the
c) Proprioceptors body in space. Chemoreceptors are located
d) Mechanoreceptors in the taste buds and epithelium of the nasal
cavity. They play
a role in taste and smell. Thermoreceptors
in the skin detect variations in temperature.
Mechanoreceptors
in the skin and hair follicles detect touch,
pressure, and vibration.
2. Which structure within the ANS: A

brain is responsible for con- The reticular activating system, located in
sciousness and alertness? the brainstem, controls consciousness and
alertness. The
a) Reticular activating system cerebellum maintains muscle tone, coordi-
b) Cerebellum nates muscle movement, and controls bal-
c) Thalamus ance. The thalamus is a
d) Hypothalamus relay system for sensory stimuli. The hypo-
thalamus controls body temperature.
3. The nurse has been teach- ANS: B

ing a parent about stimuli to Exposure to voices, music, and ambient
develop her infant's audito- sound helps develop the infant's auditory
ry nervous system. Which be- nervous system.
havior by a parent toward the Cuddling, feeding, and soothing provide
child provides evidence that comfort and pleasure and teach the infant
learning occurred? about his external
environment.
a) Cuddling
b) Speaking
c) Feeding
d) Soothing
1 / 26
4. A patient complains to the ANS: D
nurse that since taking a med- The nurse should document excessively dry
ication he has suffered from mouth as xerostomia. Exophthalmos is ab-
excessively dry mouth. What normal bulging of
term should the nurse use to the eyeballs that commonly occurs with thy-
document this complaint? rotoxicosis. Anosomia is losing the sense of
smell. Insomnia
a) Exophthalmos is inability to sleep.
b) Anosomia
c) Insomnia
d) Xerostomia
5. Which nursing diagnosis has ANS: C

the highest priority for a pa- The patient with impaired tactile perception
tient with impaired tactile per-
is unable to perceive touch, pressure, heat,
ception? cold, or pain,
placing him at risk for injury. Self-Care Deficit:
a) Self-Care Deficit: Dressing Dressing and Grooming, Impaired Adjust-
and Grooming ment, and
b) Impaired Adjustment Activity Intolerance are also likely to be ap-
c) Risk for Injury propriate for this patient, but are not as high
d) Activity Intolerance a priority as Risk
for Injury. Risk for Injury is directly related to
safety, which must always be a priority.
6. The nurse is caring for ANS: C

a patient with dementia Soft, calming music is sometimes helpful for
who becomes agitated every patients with dementia. Encouraging a family
evening. Which intervention member to sit
by the nurse is best for calm- with the patient might have a calming effect,
ing this patient? but the option does not provide for that during
the evening
a) Encouraging family mem- when the patient is symptomatic. Applying
bers to visit only during the bilateral wrist restraints might further agitate
day the patient.
b) Applying wrist restraints Lorazepam will provide sedation but might
during periods of agitation cause further confusion.
c) Playing soft, calming music
during the evening
2 / 26
d) Administering lorazepam
(a tranquilizer)
7. Which intervention is appro- ANS: C

priate for the patient with The nurse should assess for sores or open
a nursing diagnosis of Dis- areas in the mouth and provide frequent oral
turbed Sensory Perception: hygiene. The nurse
Gustatory? should also teach the patient to eat foods
separately to allow the taste of food to be
a) Limit oral hygiene to one distinguishable.
time a day. Seasonings, salt substitutes, spices, or
b) Teach the patient to com- lemon may improve the taste of foods, so the
bine foods in each bite. patient should not
c) Assess for sores or open avoid them.
areas in the mouth.
d) Instruct the patient to avoid
salt substitutes.
8. A patient diagnosed with ANS: A

macular degeneration asks Macular damage (degeneration) causes
the nurse to explain his condi- diminished central vision. Cataracts are
tion. Which statement by the caused by a cloudy lens
nurse best describes macular and result in blurred vision. Glaucoma is
degeneration? pressure in the anterior cavity of the eye,
which shifts the lens
a) "The portion of your eye position. Astigmatism is irregular curvature
called the macula, which is re- of the cornea, resulting in blurred vision.
sponsible for central vision, is
damaged."
b) "Your lens became cloudy,
causing your blurred vision.
This cloudiness will increase
over time."
c) "The pressure in the anteri-
or cavity of your eye became
elevated, shifting the position
of your lens."
d) "There's an irregular curva-
3 / 26
ture of your cornea, causing
your blurred vision."
9. A patient who sustained a ANS: D

head injury in a motor vehi- Central deafness results from damage to the
cle accident has damage to auditory areas in the temporal lobes. Oto-
the temporal lobe. This injury sclerosis is
places the patient at risk for hardening of the bones of the middle ear,
which type of hearing loss? especially the stapes. Conduction deafness
results when one of
a) Otosclerosis the structures that transmits vibrations is af-
b) Conduction deafness fected. Presbycusis is a progressive sen-
c) Presbycusis sorineural loss
d) Central deafness associated with aging.
10. A patient comes to the clinic ANS: B

complaining of a taste distur- Phenytoin is a medication that has a high
bance. Which medication that incidence of associated taste disturbance.
the patient is currently pre- Furosemide,
scribed is most likely respon- glyburide, and heparin are not implicated in
sible for this disturbance? taste disturbances.
a) Furosemide, a diuretic
b) Phenytoin, an anticonvul-
sant
c) Glyburide, an antidiabetic
d) Heparin, an anticoagulant
11. Which instruction should the ANS: D

nurse be certain to include The nurse should instruct the visually im-
when providing discharge paired patient to avoid using throw rugs on
teaching for a patient who has
the floors at home.
a serious visual deficit? She should instruct the patient with a hearing
deficit to install blinking lights to alert him to
a) Install blinking lights to an incoming
alert an incoming phone call. phone call. She should instruct the patient
b) Have gas appliances in- with an olfactory deficit to have gas appli-
spected regularly to detect ances inspected
gas leaks. regularly to detect leaks. The patient with
4 / 26
c) Wear properly fitting shoes a tactile deficit should be instructed to use
and socks. properly fitting shoes and socks.
d) Avoid using throw rugs on
the floors.
12. The nurse must irrigate the ANS: C

ear of a 4-year-old child. How The nurse should straighten the ear canal of
should the nurse pull the pin- a small child by pulling the pinna down and
na to straighten the child's back. To
ear canal? straighten the ear canal of an adult, the nurse
should pull the pinna up and outward.
a) Up and back
b) Straight back
c) Down and back
d) Straight upward
13. Which step should the nurse ANS: A

take first when performing The nurse should warm the irrigation solution
otic irrigation in an adult? to room temperature first. Next, the nurse
should assist the
a) Warm the irrigation solu- patient into a sitting position, with the head
tion to room temperature. tilted away from the affected ear; straighten
b) Position the patient so she the ear canal by
is sitting with her head tilted pulling up and back on the pinna; place the
away from the affected ear. tip of the nozzle into the entrance of the ear
c) Straighten the ear canal by canal; and direct
pulling up and back on the the stream of irrigating solution gently along
pinna. the top of the ear canal toward the back of
d) Place the tip of the nozzle the patient's head.
into the entrance of the ear Then continue irrigating until the canal is
canal. clean.
14. Which essential oil might the ANS: C

nurse trained in aromathera- Rosemary is stimulating and uplifting for
py use to uplift and stimulate many people. Lavender, Roman chamomile,
a patient? and ylang-ylang
are used to promote relaxation.
a) Lavender
b) Roman chamomile
5 / 26
c) Rosemary
d) Ylang-ylang
15. Which assessment finding ANS: A

is considered an age-related Presbycusis, the loss of high-frequency
change? tones, is an age-related change. Hyperopia
is the ability to see
a) Presbycusis distant objects well; it is not an age-related
b) Hyperopia change. The ability to perceive touch and
c) Increased sensitivity to taste diminishes
touch with age; it does not increase.
d) Increased sensitivity to
taste
16. After sustaining a stroke, the ANS: B

patient lacks attention to the This patient lacks attention to the right side of
right side of his body. Which his body after sustaining a stroke; therefore,
nursing diagnosis best de- the most
scribes the patient's prob- appropriate nursing diagnosis is Unilateral
lem? Neglect. The patient may also have Dis-
turbed Sensory
a) Disturbed Sensory Percep- Perception, Risk for Peripheral Vascular Dys-
tion function, and Acute Confusion, but they are
b) Unilateral Neglect not the most
c) Risk for Peripheral Vascular appropriate for the defined problem.
Dysfunction
d) Acute Confusion
17. A patient complains of an im- ANS: C

paired sense of smell. Which The olfactory nerve is responsible for the
cranial nerve might have been sense of smell. Damage to this nerve causes
affected? an impaired sense
of smell. The trigeminal nerve transmits stim-
a) Trigeminal uli from the face and head. The glossopha-
b) Glossopharyngeal ryngeal nerve is
c) Olfactory responsible for taste. The vagus nerve is re-
d) Vagus sponsible for sensations of the throat, larynx,
and thoracic and
abdominal viscera.
6 / 26
18. Which intervention is helpful ANS: D
when caring for a patient with The nurse should place the patient's eye-
impaired vision? glasses within easy reach and make sure
that they are clean and in
a) Suggest the patient use good repair. The patient should have suffi-
bright overhead lighting. cient light but avoid bright light, which might
b) Advise the patient to avoid cause glare. The
wearing sunglasses when patient should be encouraged to wear sun-
outdoors. glasses, visors, or hats with brims when out-
c) Do not offer large-print doors. A magnifying
books, as this may embarrass lens or large-print books may be helpful.
the patient.
d) Place the patient's eye-
glasses within easy reach.
19. A patient tells the nurse that ANS: A

since taking a medication he Many medications cause xerostomia (dry
has suffered from excessive- mouth), and xerostomia is the most common
ly dry mouth. Which of the cause of impaired
following assessments would taste. Impaired sense of smell also affects
be needed to plan interven- the sense of taste; however, there is no rea-
tions for that symptom? son to assume
impaired smell in this patient. Balance is
a) Asking the patient whether related to the inner ear and to kinesthetic
foods taste different now sense, not to taste and
b) Checking the patient's xerostomia. Xerostomia would be related to
sense of smell seizures only if a patient experienced dry
c) Having the patient stand to mouth as an aura;
check for balance this would be unusual. Even if this were the
d) Assessing for a history of case, the information would allow the nurse
seizures to plan care for
seizures, but not for the symptom of dry
mouth.
20. The nurse caring for a ANS: D

fussy newborn uses which In the first months of life until the autonomic
of the following interventions nervous system matures, newborns are eas-
to calm the baby and reduce ily overstimulated
sensory overload? by the loud noises, bright light, high-contrast
7 / 26
objects (e.g., black and white mobile), and
a) Rubbing the baby's back stroking sensitive
b) Singing and rocking the areas (back and bottom of feet). Stroking the
baby back or bottom of feet can be too much for
c) Hanging a black and white the baby to
mobile handle. Newborns experience sensory over-
d) Swaddling the baby tightly load, particularly when more than one sense
is involved, such
as singing (auditory) and rocking (kinesthet-
ic).
21. The patient at the clinic says ANS: C

to the nurse, "My doctor Myopia, or nearsightedness, means that the
checked my eyes and told person is able to see close objects well but
me my vision was 20 over not distant objects.
100 [20/100]. What does that For example, a person with 20/100 vision can
mean?" What is the best re- see an object from 20 feet away that a person
sponse by the nurse? with normal
sight could see from a distance of 100 feet.
a) "This means that your eye Hyperopia, or farsightedness, implies that
pressure readings are quite the eye sees distant
high and may be indicative of objects well. A person with hyperopia may
glaucoma." have 20/10 vision—he can see an object
b) "These are numbers asso- form 20 feet that a
ciated with left and right eye normal eye can see from 10 feet. Glaucoma
readings for identifying mac- is a type of vision loss caused by increased
ular degeneration." pressure in the
c) "This could be nearsight- anterior cavity of the eyeball resulting in loss
edness. Your vision for seeing of peripheral vision. The fraction 20/100 is
objects up close is better than unrelated to
your vision for seeing things glaucoma. Macular degeneration is the loss
in the distance." of central vision due to damage to the mac-
d) "This could be that you ula lutea, the
are farsighted. Your vision for central portion of the retina. This results in
seeing objects in the distance loss of central and near vision. The fraction
is better than it is for seeing 20/100 is
objects up close." unrelated to identifying macular degenera-
tion.
8 / 26
22. The home health nurse is de- ANS: C
veloping a plan of care for The priority nursing diagnosis for a patient
her patient with a visual im- with a visual impairment is Risk for Falls. The
pairment. What is the priority patient, owing
nursing diagnosis for this pa- to a visual impairment, may have deficits
tient? with feeding, dressing, and social interaction;
however, the
a) Self-Neglect highest priority is promoting safety and re-
b) Social Isolation ducing the patient's risk for falls.
c) Risk for Falls
d) Risk for Imbalanced Nu-
trition: Less Than Body Re-
quirements
23. The nurse is assessing an ANS: C

elderly male in the nursing To assess level of orientation, the best ques-
home. What question will the tion is to ask the patient for his name, date,
nurse ask this patient to best and his current
assess his level of orienta- location. Asking the patient to repeat a se-
tion? quence of words (e.g., glasses, rocket, truck)
assesses recall and
a) "Will you please repeat recent memory. Asking a patient for the date
these three words for me: of retirement assesses long-term memory
glasses, rocket, truck?" but does not reflect the patient's orientation
b) "Can you tell me the date status to the present time and situation. Ask-
of your retirement from your ing a patient what he ate for breakfast as-
workplace?" sesses short-term memory only.
c) "What is your name and to-
day's date? Can you tell me
where you are?"
d) "What did you eat for break-
fast this morning?"
24. The 80-year-old patient on ANS: B

the medical-surgical unit says A cataract is a cloudy film over the lens of the
to the nurse, "My vision eye resulting in blurred vision, sensitivity to
is blurry and I see halos glare and
around lights. The glare from bright light, halos around lights, fading or
the sun really bothers me." yellowing of colors, and image distortion. Tin-
9 / 26
Upon assessment, the nurse nitus is ringing in
notes a cloudy film over the the ear unrelated to vision. Presbyopia is a
lens of the eye. Based on change in vision associated with aging in
the patient's complaints and which a person is
the nurse's assessment, the less able to accommodate to near objects.
nurse associates Glaucoma is a condition involving increasing
these findings with which of pressure in the
the following? eye that can lead to loss of peripheral vision
and even blindness, if not treated. Strabis-
a) Strabismus mus ("crossed-
b) Cataracts eyes") is the condition wherein one eye devi-
c) Glaucoma ates from a fixed image.
d) Presbyopia
25. For a patient with hearing ANS: A, D

loss, it is essential to mini- Aspirin and furosemide may cause ototox-
mize the risk of further dam- icity, leading to auditory nerve impairment.
age to the auditory nerve. Digoxin,
Which of the following med- famotidine, or penicillin does not place the
ications may need to be dis- patient at risk for auditory nerve impairment.
continued if the patient is tak-
ing
them? Select all that apply.
a) Furosemide, a diuretic
b) Digoxin, a cardiotonic
c) Famotidine, an antacid
d) Aspirin, an analgesic
e) Penicillin, an antibiotic
26. Which factors in a health his- ANS: A, C, E

tory place a patient at risk for Having had frequent ear infections (otitis me-
hearing loss? Select all that dia) places a patient at risk for hearing loss
apply. because of
scarring that may have occurred. Older
a) Being an older adult adults experience a generalized decrease in
b) Childhood chickenpox the number of nerve conduction fibers and
c) Frequent otitis media structural changes in the ear, which cause
hearing loss. Sensorineural deafness, eye
10 / 26
d) Diabetes mellitus abnormalities, and congenital heart disease
e) Congenital rubella are the classic triad that occurs with congen-
ital rubella.
Chickenpox and diabetes mellitus do not
place the patient at risk for hearing loss.
27. The nurse caring in the in- ANS: A, B

tensive care unit suspects The patient with sensory overload might ex-
that one of her patients is hibit disorientation, confusion, restlessness,
experiencing sensory over- decreased
load. Which findings would in- attention span and ability to perform tasks,
crease her suspicion? Select anxiety, muscle tension, and difficulty sleep-
all that apply. ing. Sensory
deprivation also leads to irritability, confu-
a) Disorientation sion, reduced problem-solving, and impaired
b) Restlessness attention span; but
c) Hallucinations unlike sensory overload, the person with
d) Depression sensory deficit experiences depression, pre-
e) Preoccupation with somat- occupation with
ic complaints somatic complaints, hallucinations, and delu-
sions.
28. Which actions can the nurse ANS: B, C, D, E

take to prevent sensory over- To prevent sensory overload, minimize un-
load? Select all that apply. necessary light, plan care to provide uninter-
rupted periods of
a) Leave the television on low sleep, and speak to the patient in a moderate
volume to block out other tone of voice using a calm and confident
noises. manner. Television
b) Minimize ambient light in can be used to provide sensory stimuli, but
the patient's room. not to prevent sensory overload. When used,
c) Plan care to provide peri- it should not be
ods of sleep. left on indiscriminately. Medications and
d) Speak with a moderate some substances that stimulate the CNS
tone of voice. may also contribute tosensory overload,
e) Restrict caffeine intake dur- such as caffeine.
ing hospitalization.
29.
11 / 26
For an unconscious patient, ANS: A, C, D
which of the following in- Safety measures are a priority for uncon-
terventions are necessary to scious clients. Keep the bed in low position
provide for patient safety? Se-
when you are not at
lect all that apply. the bedside, and keep the siderails up. If the
patient's blink reflex is absent or her eyes do
a) Talk to the patient as you not close totally,
provide care. you may need to give frequent eye care to
b) Incorporate more touch in keep secretions from collecting along the
the plan of care. lid margins. The eyes may be patched to
c) Give frequent eye care if prevent corneal drying, and lubricating eye
blink reflex is absent. drops may be ordered. It is important to
d) Keep the siderails up and talk to the patient because the sense of hear-
bed in low position. ing may still be intact. This provides some
e) Perform diligent oral care stimulation and
by irrigating with diluted may help with reality orientation. Providing
mouthwash. touch will also help prevent sensory deficit;
however, it is not
a safety measure. The unconscious patient
would have a minimal or absent gag reflex
and lack of
swallowing; therefore, you would not squirt
fluid in the mouth for oral care because it
could cause the
patient to aspirate.
30. Which of the following inter- ANS: A, B

ventions are best for prevent-Talking to the patient while providing care is
ing sensory deficit for a resi-
not only important for personal and meaning-
dent in a long-term care facil-
ful interaction,
ity? Select all that apply. but also reduces social isolation and sensory
deprivation. If the patient consents, you can
a) Talk to the patient as you stimulate the,sense of touch by brushing his
provide care. hair or giving a back rub, for example. How-
b) Incorporate touch when ever, use touch carefully,
providing care. considering personal and cultural prefer-
c) Turn on bright, fluorescent ences, while observing the patient's reaction.
light for reading. Provide enough
d) Encourage waiting to drink light, but avoid glare; use soft, diffuse light-
12 / 26
water until after the meal. ing, not bright, fluorescent light. Teach clients
e) Offer spicy seasoning for to drink water
the resident to use on food. between bites (not waiting until after the
meal) to distinguish the taste of the food
more readily.
Seasonings, salt substitutes, spices, or
lemon may improve the taste of foods and
encourage the client's
appetite. But avoid overseasoning food with
excessively spicy food that overpowers the
person's sense of
taste.
31. For a patient with dementia, ANS: A, B, D, E

how might the nurse best im- Place personal objects, photos, and memen-
prove orientation and clarity? tos in the immediate environment, and dis-
Select all that cuss them with the
apply. client. Introduce yourself and state the
client's name each time you meet with him;
a) Place personal objects wear a readable (large,
where the patient can see plain type) nametag to reinforce your intro-
them. duction. Also identify the day, date, and time
b) Introduce yourself each as you interact.
time you have contact with Encourage the patient to participate in fa-
the patient. miliar activities, such as bathing. To promote
c) Encourage the patient to re- patient orientation
lax while the nurse gives the for a patient with confusion (e.g., demen-
bath. tia), use simple communication and offer few
d) Use short sentences with choices with ADLs
only a few words. to prevent from overwhelming the patient.
e) Do not offer many choices While you may sometimes find it necessary
when it comes to ADLs. to bathe the
patient, that intervention wouldn't be expect-
ed to improve orientation. Furthermore, en-
couraging the
patient to relax would likely be ineffective in
relaxing the patient, and might even elicit
anger.
13 / 26
32. Sensory changes that occur ANS: A, B, C
with aging include which of A decreased number of nerve conduction
the following? Select all thatfibers resulting in slower reflexes, less flex-
apply. ibility of the lens
resulting in decreased ability to focus on near
a) Decreased number of nerve objects, and atrophy of taste buds resulting
conduction fibers results in in decreased
slower reflexes. ability to taste are all sensory changes that
b) The lens of eye becomes occur with aging. Regulation of body temper-
less flexible and less able to ature is not a
focus on near objects. sensory deficit. Cerumen is drier and more
c) Taste buds atrophy and solid with aging, creating hearing loss.
decrease in number, causing
decreased ability to perceive
taste.
d) Impaired regulation of
body temperature causes an
increased risk for seizures.
e) The amount and waxiness
of cerumen increases with ag-
ing.
33. Which of the following areas ANS: A, B, C, E

would the nurse include in a The mental status assessment includes
mental status assessment for assessment of behavior, appearance, re-
an adult patient? Select all sponse to stimuli, speech,
that apply. memory, and judgment. Normal findings in-
clude an ability to express and explain real-
a) Behavior istic thoughts with
b) Judgment clear speech, follow directions, listen, an-
c) Knowledge swer questions, and recall significant past
d) Reflexes events. Assessment of
e) Appearance reflexes is associated with a complete and
in-depth neurological assessment.
34. The nurse in the intensive ANS: B, D, E

care unit enters her patient's When a seizure is occurring, the nurse would
room and observes the pa- turn the patient to his side to prevent aspira-
tient is experiencing a tion and loosen
14 / 26
seizure. What are the most ap- any restrictive clothing; also pad the head,
propriate interventions by the foot, and siderails of the bed and place oral
nurse? Select all that apply. suction at the
bedside. Do not try to open the mouth and
a) Insert a padded tongue insert a tongue depressor. This action could
depressor in the patient's result in injury to
mouth. the patient or injury to the nurse (biting). Also
b) Turn the patient to his side. do not attempt to restrain the patient, as this
c) Restrain the patient to con- may result in
trol his jerking movements. muscle and joint injury.
d) Loosen any restrictive
clothing.
e) Pad the siderails of the pa-
tient's bed.
35. Which of the following tasks ANS: C, D

may be delegated to a certi- A CNA may obtain vital signs and suction the
fied nursing assistant (CNA)? patient's oropharynx postseizure and may
Select all that apply. perform the tasks
of setting up seizure precautions, which in-
a) Irrigating the ear of a child cludes padding the side of the bed to prevent
with impacted cerumen injury. A CNA
b) Administering eye drops may not perform ear irrigation or adminis-
for a patient in a coma ter eye drops, as these interventions require
c) Obtaining vital signs every knowledge, skills,
15 minutes after a seizure and assessment of the professional nurse.
d) Padding the sides of a bed
for seizure precautions
e) Suctioning the patient's
oropharynx after a seizure
36. What are some positive ef- ANS: A, C, D

fects of pet therapy for resi- Many facilities have resident pets or can
dents in a long-term care fa- arrange to have pets visit. Pet therapy can
cility? Select all that apply. increase socialization,
lower blood pressure, and decrease loneli-
a) Increases socialization ness and perception of pain.
b) Increases blood pressure
c) Decreases pain
15 / 26
d) Decreases loneliness
e) Decreases insomnia
37. Which of the following pop-ANS: A, B, C

ulations are considered high
A nonstimulating, monotonous environment
risk for sensory deprivation?
increases the risk for sensory deprivation,
Select all that apply such as people
who are in prison or who are homebound.
a) The homebound Patients with depression are at risk for sen-
b) Those in prison sory deprivation, as
c) Those who are depressed they might be withdrawn from others and ac-
d) Those experiencing high tivities or less apt to interact within the usual
anxiety context of their
e) Those feeling pain lives. Patients with anxiety often experience
sensory overload. Pain lowers the threshold
for processing
sensory input, which increases the risk for
sensory overload.
38. The pediatric nurse educator ANS: A, B, C, E

is preparing a teaching plan The most common reason for seizures in a
for seizure prevention for par- person with epilepsy is failure to take pre-
ents of children with seizures. scribed antiseizure
Which of the following can medication. Other common triggers of
trigger seizures? Select all seizures are illness and fever, sleep depriva-
that apply. tion, stress, and
ingestion of mood-altering substances. Addi-
a) Fever tionally, high-contrast patterns and flashing
b) Video games or flickering
c) Sleep deprivation lights (video games, strobe lights) can pro-
d) Food allergens voke seizure activity. Ingesting a food aller-
e) Mood-altering substances gen invokes an
immunological response with reactions relat-
ed to anaphylaxis.
39. Which of the following med- ANS: A, B, C, E

ical conditions has a direct ef- Diseases that affect circulation may impair
fect on sensory function con- function of the sensory receptors and the
tributing to sensory deficits? brain, thereby
16 / 26
Select all that apply. altering perception and response. Some dis-
eases affect specific sensory organs. Diabet-
a) Diabetes ic retinopathy is the
b) Hypertension leading cause of blindness among adults
c) Multiple sclerosis ages 20 to 74. Hypertension, too, can dam-
d) Breast cancer age the retina of the
e) Zinc deficiency eyes. Neurological disorders, such as multi-
ple sclerosis, slow the transmission of nerve
impulses. There is
no indication that breast cancer leads to
sensory deficits. Zinc deficiency can cause
anosmia, which is
reduced sense of smell.
40. A nurse is preparing to give D

a client an injection. As the
nurse begins to give the
injection, the client winces
and withdraws. Which factor
affecting sensory response
does this demonstrate?
A.) Contrast
B.) Intensity
C.) Adaptation
D.) Previous experience
41. Cuddling, feeding, and rock- A

ing an infant provide which
type of stimulation?
A.) Tactile
B.) Auditory
C.) Visual
D.) Olfactory
42. An individual's response to A,C,D,E

stimuli is based on which fac-
tors? Select all that apply.
17 / 26
A.) Contrast
B.) Medication
C.) Adaptation
D.) Previous experience
E.) Intensity
43. A nurse is caring for a A

client who is confused. Which
would be the most appropri-
ate way to approach bathing
the client?
A.) State "Time for a bath."

B.) State "Let's get everything
together and I will help you
with your bath after I finish
taking vital signs."
C.) Do not tell the client the
intention.
D.) Ask, "Would you like to
take a bath now?"
44. Which receptor is stimulat- B

ed by an unpleasant tasting
medication?
A.) Olfactory
B.) Gustation
C.) Auditory
D.) Tactile
45. Which is likely to happen in B

a person who has long-term
blindness?
A.) Other senses will gradual-

ly diminish.
B.) Other senses will likely
18 / 26
sharpen.
C.) The person may suffer
from sensory deprivation.
D.) Over time, anxiety will de-
velop.
46. Which type of seizure re- A

sults from widespread electri-
cal activity on both sides of
the brain at once?
A.) Generalized seizure

B.) Partial seizure
C.) Absence seizure
D.) Febrile seizure
47. Which can occur as a result A,B,E

of sensory decline in older
adults? Select all that apply.
A.) Depression
B.) Social isolation
C.) Fatigue
D.) Decline in physical activity
E.) Hallucinations
48. Which describes perception? A
A.) The ability to interpret im-

pulses transmitted from the
receptors that give meaning
to the stimuli
B.) The process of receiving
stimuli in the nerve endings
C.) A response to stimuli that
declines over time
D.) Anything that stimulates a
nerve receptor
49. A,C,E
19 / 26
Which strategies might be ef-
fective at preventing sensory
overload in ICU clients? Se-
lect all that apply.
A.) Keep lights low at night.

B.) Keep lights on at all times
to prevent disorientation.
C.) Reduce sounds in and
around the area.
D.) Perform one action at a
time when providing care.
E.) Limit the number of times
the client must be awakened.
50. Which is an appropriate in- C

tervention for a client who is
blind?
A.) Speak loudly to the client.

B.) Move all items out of reach
to prevent injury.
C.) Introduce self when enter-
ing the room.
D.) Avoid speaking to the
client to prevent confusion.
51. Which is an appropriate in- C

tervention for a client with a
hearing deficit?
A.) Avoid talking to the client

because this causes frustra-
tion.
B.) Speak only to family mem-
bers.
C.) Face the client directly and
speak loudly and clearly.
20 / 26
D.) Communicate by writing
to avoid confusion.
52. Which strategies are often A,D,E

effective in relieving anxiety
and fear in clients with de-
mentia? Select all that apply.
A.) Establish a predictable

routine.
B.) Tell the client not to worry.
C.) Correct the client if he or
she makes an incorrect state-
ment.
D.) Use the same caregivers
each day if possible
E.) Use alternative therapies
53. Which nursing action can A

manage unpleasant olfactory
stimuli?
A.) Emptying commodes and

bedpans immediately
B.) Removing clutter in the
client room
C.) Turning lighting down in
the client room
D.) Reducing noise in the unit
outside client rooms
54. ICU psychosis occurs as a re- A

sult of which situation?
A.) Sensory deprivation

B.) Sensory overload
C.) Visual dysfunction
D.) Auditory dysfunction
55. D
21 / 26
Which part of the brain
controls consciousness and
alertness?
A.) Cerebral cortex

B.) Temporal area
C.) Parietal area
D.) Reticular activating sys-
tem
56. Which are examples of adap- A,C

tation? Select all that apply.
A.) Living next to train tracks

and not being bothered by the
sound of the trains after a pe-
riod of time
B.) Taking an unpleasant tast-
ing medicine because it is
beneficial
C.) Not hearing a loud ticking
of a clock after hearing it over
time
D.) Understanding that un-
pleasant odors must be re-
moved immediately
E.) Hearing loss from expo-
sure to repeated loud noises
57. Where is the sense of vision A

perceived in the brain?
A.) Occipital lobes

B.) Temporal lobes
C.) Parietal lobes
D.) Brainstem
58. Which are examples of B

chemoreceptors?
22 / 26
A.) The retina of the eye

B.) Taste buds
C.) Hair cells
D.) Temperature detection in
skin
59. Which statement best de- D

scribes adaptation in relation
to sensory perception?
A.) Adaptation involves a

stimulus and how the brain
recognizes it.
B.) Adaptation is the process
of receiving stimuli and trans-
mitting the impulse.
C.) Adaptation is the sense a
person has of how his or her
own body is positioned.
D.) Adaptation is how a per-
son becomes accustomed to
a sound or odor that is pre-
sent for an extended period of
time.
60. Which factors affect the per- C,D,E,F

ception of a stimulus? Select
all that apply.
A.) Position of the stimulus

B.) Prior stimuli experience
C.) Location of the receptors
D.) Number of receptors acti-
vated
E.) Frequency of action po-
tentials generated
F.) Changes in frequency, lo-
cation, and number of stimuli
23 / 26
61. Which stimulates an infant's D
tactile senses?
A.) Lights and colors

B.) Mother's voice
C.) Smell of breast milk
D.) Holding and cuddling
62. The nurse is working with A,B,E,F

the family members who re-
ports their elderly parent has
decreased visual and hear-
ing acuity. Which clinical man-
ifestations should the nurse
instruct the family to report?
Select all that apply.
A.) Withdrawal
B.) Depression
C.) Aggression
D.) Combative
E.) Hallucinations
F.) Social isolation
63. The nurse is caring for a client D

with osteomyelitis who is di-
agnosed with hearing loss
related to long-term medica-
tion use. Which medication
may have caused this senso-
ry loss?
A.) Lisinopril (Zestril)

B.) Vinblastine (Velban)
C.) Atorvastatin (Lipitor)
D.) Gentamicin (Garamycin)
64. Which factors could cause a A,B,C,D

person to develop a partial
24 / 26
seizure? Select all that apply.
A.) Meningitis
B.) Head trauma
C.) Brain tumors
D.) Sleep deprivation
E.) Hereditary factors
F.) High levels of anticonvul-
sants
65. The nurse enters a room A

and notes the client's eyes
are closed. The nurse says
the client's name without re-
sponse. What should be the
nurse's next action?
A.) Touch the client.

B.) Call a Code Blue.
C.) Perform a sternal rub.
D.) Obtain an interpreter.
66. The home health nurse en- B

ters the apartment of an el-
derly client who lives alone
and immediately determines
the client has a hearing im-
pairment. Which finding sup-
ports this conclusion?
A.) The house has all the

lights on in every room.
B.) The television is on very
loud in the same room as the
client.
C.) There is a magnifying
glass laying on the bedside
table.
D.) The nurse spots assistive
25 / 26
devices such as a wheeled
walker.
67. The nurse is developing a D

plan of care for a client
with new hearing aids. Which
long-term goal is most appro-
priate for the client?
A.) The client will wear the

hearing aids 90% of the time.
B.) The client will demon-
strate successful insertion of
the hearing aids.
C.) The client will verbalize an
understanding of the need for
hearing aids.
D.) The client will demonstrate
how to properly care for the
hearing aids within 2 weeks.
68. Which are conditions that can A,C,E

affect sensory organs? Select
all that apply
A.) Diabetic retinopathy

B.) Cancer
C.) Hypertension
D.) Kidney infection
E.) Sickle Cell Disease
26 / 26

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NURS 3230 Chapter 43 Sensory Functioning NCLEX

Study online at https://quizlet.com/_1oydk9

1. The plan of care for a client exhibit- Answer:

2. The nurse is preparing to reposition Answer:

3. The nurse determines that when a Answer:

4. During the nurse's morning assess- Answer:

5. A hospital client has been awakened Answer:

6. The nurse is assessing a neglect- Answer:

7. A nursing instructor is speaking to Answer:

8. A nurse explains to a client what he Answer:

9. Which of the following situations Answer:

10. A special needs child has been Answer:

11. A hospitalized client who refuses Answer:

12. Which of the following clients is most Answer:

13. A child 4 years of age has a moth- Answer:

14. A client returning from the oper- Answer:

16. An older adult client who is in a Answer:

17. A client has expressed great relief at Answer:

18. A cycling accident has resulted in Answer:

19. A resident of a long-term care facili- Answer:

a. Minimize background noises and Rationale:

20. Which of the following clients is ex- Answer:

21. A client brought to the emergency Answer:

23. A client informs the nurse that she is Answer:

24. A nurse in a family clinic asks a client, Answer:

25. To meet the learning needs of the Answer:

26. Baby J is a premature infant born 6 Answer:

a. Sensory deprivation Sensory overload

27. You enter Mrs. Angelo's room on the Answer:

29. Mr. Sweet, patient known to you due Answer:

a. Eye trauma - due to fall - stabilize,

30. A nurse who is assessing an older fe- Answer:

31. A nurse is assessing a 78-year-old Answer:

32. A nurse asks a patient to close her Answer:

33. A nurse observes that a patient who Answer:

34. Which action would be most impor- Answer:

35. A patient is in the late stages of AIDS, Answer:

36. Which patient would a nurse assess Answer:

a. An older man confined to bed at Rationale:

37. A patient in an intensive care burn Answer:

38. A patient's spinal cord was severed, Answer:

39. A nurse is diagnosing an 11-year-old Answer:

41. In a group home in which most pa- Answer:

42. A nurse formulated the following Answer:

a. The infant's parents lack motiva-

43. A nurse formulates the following di- Answer:

44. An older female patient has a se- Answer:

1. The nurse assessing a neglected child C: sensory deprivation

2. The patient brought to the emergency C: Coma

3. A special needs child has been placed D: sensory overload

4. A nursing instructor is speaking to a D: demonstrating or pantomim-

5. A patient returning from operating room B: talk to the patient in a normal

8. The nurses assessing a patient's gus- B: tell me at the taste on your

9. The patient informs nurse that she is not A: impaired memory

14. Which of the following patients is experi- B: a patient who is experiencing

15. A cycling accident has resulted in a head A: Disturbed sensory perception;

A: Disturbed sensory perception; senso-

17. A patient has expressed great relief at C: sensory reception

19. Mr. Feilds is a resident of a long-term B: minimize background noises

1. The nurse checks a patient's ANS: B

2. Which structure within the ANS: A

3. The nurse has been teach- ANS: B

5. Which nursing diagnosis has ANS: C