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NURS 3000 FINAL EXAM – Questions With Indepth
Solutions
Save
Terms in this set (93)
Signs of visual impairment Poor coordination, falls, squinting, repositions
objects
Signs of auditory impairment Blank looks, speaking loudly, decreased attention
span, inappropriately smiling and nodding, ringing in
ears
Signs of gustatory / olfactory deficits - Excessive seasoning, changes in appetite,
complaints of food tasting different / bad
- Increased body odor, failure to react to strong
odors, increased sensitivity to odors
Signs of tactile deficits No response when touched, increased or decreased
reaction to pain, clumsiness, numbness
- Positioning: poor balance, shuffling, decreased
response to brace self when falling, deliberate
movements
What might cause disruptions in the - Loud noises
normal sensory process? - Excessive / reduced stimuli
- Damage to sensorineural pathways / nerve damage
- Genetic disorders (autism, OCD)
Vibratory sensation sensory pathway to detect vibrations by touch
Kinesthetic sensation Awareness of body position and movements
,Stereognosis Awareness of object's shape, size, texture from touch
Visceral sensation Awareness of internal organs and sensation
How to assess and document LOC / - Alert: readily responds to all stimuli appropriately
orientation - Drowsy: lethargic, groggy, responses slow or
delayed; arousable
- Stupor: arouses with greater stimulation, shaking,
reactions decreased and inappropriate
- Semi coma: minimally aroused by painful stimuli
- Coma: no consistent response to any stimuli;
reflexes depressed or absent; pupils may not
respond
Clients at high risk for various sensory - Immobilized
disturbances - Isolated
- Elderly
- Confused
- Terminally ill
- Sensory deficit
- Acutely ill; ICU/CCU
- In intense pain
- Those in unfamiliar environment
- Many visitors
- Decreased rest/sleep
Sensory deprivation - Caused by restricting environment, decreased input
from impaired senses, meaningless stimuli
- Boredom, restlessness, decreased attention span,
emotional liability, disorganized thought, anxiety,
hallucinations, increased sleep, irritability
Sensory overload - Caused by too much stimuli, stimuli without
meaning, repetitious / unchanging
- Anxiety, fear, irritability, anger outbursts,
restlessness, decreased sleep / change in sleep
patterns, crying, covering eyes / ears
, Nursing interventions for sensory - Increase stimuli and meaning
deprivation - Visit more and orient frequently
- Explain all care
- Place TV, radio, clock, calendar in room
- Display pictures, cards, familiar objects
- Touch more
- Offer variety of foods
- Elevate HOB, open door
- Assist OOB, ambulate
Nursing interventions for sensory - Decrease stimuli
overload - Decrease interruptions
- Organize care to accomplish more at once
- Close door, turn off TV, decrease odors
- Restrict visitors, calls
- Decrease noise levels
- Provide comfort measures to decreased pain
Hypotheses / problem statements r/t ...
disruptions in sensory needs
How can nurse assist clients who are - Provide knowledge about sexuality and sexual
dealing with sexuality issues? phenomena
- Positive body image
- Self-awareness or appreciation for one's
attitudes/feelings related to sexuality
- Value systems that enhance sexual decision making
- Effective relationships with members of both
genders
- Emotional comfort with one's sexual activities
- Capacity for physical and psychosexual
responsiveness, which is enhancing to self and others
What is the greatest aspect of SELF-CONCEPT
sexuality?
NURS 3000 FINAL EXAM – Questions With Indepth
Solutions
Save
Terms in this set (93)
Signs of visual impairment Poor coordination, falls, squinting, repositions
objects
Signs of auditory impairment Blank looks, speaking loudly, decreased attention
span, inappropriately smiling and nodding, ringing in
ears
Signs of gustatory / olfactory deficits - Excessive seasoning, changes in appetite,
complaints of food tasting different / bad
- Increased body odor, failure to react to strong
odors, increased sensitivity to odors
Signs of tactile deficits No response when touched, increased or decreased
reaction to pain, clumsiness, numbness
- Positioning: poor balance, shuffling, decreased
response to brace self when falling, deliberate
movements
What might cause disruptions in the - Loud noises
normal sensory process? - Excessive / reduced stimuli
- Damage to sensorineural pathways / nerve damage
- Genetic disorders (autism, OCD)
Vibratory sensation sensory pathway to detect vibrations by touch
Kinesthetic sensation Awareness of body position and movements
,Stereognosis Awareness of object's shape, size, texture from touch
Visceral sensation Awareness of internal organs and sensation
How to assess and document LOC / - Alert: readily responds to all stimuli appropriately
orientation - Drowsy: lethargic, groggy, responses slow or
delayed; arousable
- Stupor: arouses with greater stimulation, shaking,
reactions decreased and inappropriate
- Semi coma: minimally aroused by painful stimuli
- Coma: no consistent response to any stimuli;
reflexes depressed or absent; pupils may not
respond
Clients at high risk for various sensory - Immobilized
disturbances - Isolated
- Elderly
- Confused
- Terminally ill
- Sensory deficit
- Acutely ill; ICU/CCU
- In intense pain
- Those in unfamiliar environment
- Many visitors
- Decreased rest/sleep
Sensory deprivation - Caused by restricting environment, decreased input
from impaired senses, meaningless stimuli
- Boredom, restlessness, decreased attention span,
emotional liability, disorganized thought, anxiety,
hallucinations, increased sleep, irritability
Sensory overload - Caused by too much stimuli, stimuli without
meaning, repetitious / unchanging
- Anxiety, fear, irritability, anger outbursts,
restlessness, decreased sleep / change in sleep
patterns, crying, covering eyes / ears
, Nursing interventions for sensory - Increase stimuli and meaning
deprivation - Visit more and orient frequently
- Explain all care
- Place TV, radio, clock, calendar in room
- Display pictures, cards, familiar objects
- Touch more
- Offer variety of foods
- Elevate HOB, open door
- Assist OOB, ambulate
Nursing interventions for sensory - Decrease stimuli
overload - Decrease interruptions
- Organize care to accomplish more at once
- Close door, turn off TV, decrease odors
- Restrict visitors, calls
- Decrease noise levels
- Provide comfort measures to decreased pain
Hypotheses / problem statements r/t ...
disruptions in sensory needs
How can nurse assist clients who are - Provide knowledge about sexuality and sexual
dealing with sexuality issues? phenomena
- Positive body image
- Self-awareness or appreciation for one's
attitudes/feelings related to sexuality
- Value systems that enhance sexual decision making
- Effective relationships with members of both
genders
- Emotional comfort with one's sexual activities
- Capacity for physical and psychosexual
responsiveness, which is enhancing to self and others
What is the greatest aspect of SELF-CONCEPT
sexuality?
