NURS 3000 final exam study guide UPDATED ACTUAL
Questions and CORRECT Answers
nursing interventions for various sensory visual: free of clutter environment;
impairments/deficits (visual, auditory, gustatory, olfactory, auditory: talk tp pt
tactile) gustatory/taste:
olfactory: remove foul odors
tactile/touch: Increase tactile stimulation through physical care measures such as
back massages, hair care, and foot soaks.; touch & hand holding
-Provide meaningful stimulation
-Provide for client's safety (e.g., assistance with ambulation and protection from
falling or from hot or sharp objects).
Normal sensory process components reception (nerve cell stim),
perception (person becomes aware of stimuli)
reaction (response/action taken)
what might cause disruption in the normal sensory -environment
process?? -meds
-cognitive/emotional resources: attitudes, values, culture, intelligence level,
anxiety
-illness: injury, trauma, dz
-age: experiences, learned responses
vibratory sense ability to feel vibration sensation
ex: tested by striking a tuning fork and then placing the vibrating fork against a
bony prominence
kinesthetic awareness of body position and movement without seeing
ex: where's the L ft, typing on keyboard without looking at keys, riding a bicycle
, stereognosis awareness of object's shape, size, texture from touch
ex: pt has eyes closed & you put coin in their hand, paper clip, pens, pencils,
coins, erasers
visceral awareness of internal organs & sensation
ex: mechanical stimuli (prostaglandins, bradykinin, hydrogen & K+ compounds can
activate visceral nociceptors & produce pain)
how to assess and accurately document lOC & -see if pt is aware of person, place, & time (alert means pt readily responds to all
orientation stimuli appropriately)
-if pt correctly responds to all 3 (oriented X3)
-if not, specify how pt isn't oriented
clients at high risk for various sensory disturbances -pts with emotional disorders
-have limited social contact with family and friends (e.g., clients from a different
culture).
-clients who have brain damage or who are taking medications that affect the
central nervous system
-have pain or discomfort
-are acutely ill and have been admitted to an acute care facility
-are being closely monitored in an intensive care unit (ICU)
sensory deprivation level of sensory input is too LOW to permit normal function
(pt isn't getting enough sensory stimuli)
sensory deprivation causes/risk factors -restricting environment
-decreased input from impaired senses
-meaningless stimuli
-immobilized; isolation
-elderly
-confused
-terminated ill
-sensory deficit
sensory deprivation s/s -boredom
-restlessness
-decreased attn span
-emotional lability
-disorganized thought
-anxiety
-hallucinations
-increased sleep
-irritability
nursing interventions for sensory deprivation -increase stimuli; meaning
-visit more; orient frequently
-explain all care
-place TV, radio, clock, calendar in room
-display pics, cards, familiar objects
-touch more
-offer variety of foods
-elevate HOB; open door
-assist OOB; ambulate
Questions and CORRECT Answers
nursing interventions for various sensory visual: free of clutter environment;
impairments/deficits (visual, auditory, gustatory, olfactory, auditory: talk tp pt
tactile) gustatory/taste:
olfactory: remove foul odors
tactile/touch: Increase tactile stimulation through physical care measures such as
back massages, hair care, and foot soaks.; touch & hand holding
-Provide meaningful stimulation
-Provide for client's safety (e.g., assistance with ambulation and protection from
falling or from hot or sharp objects).
Normal sensory process components reception (nerve cell stim),
perception (person becomes aware of stimuli)
reaction (response/action taken)
what might cause disruption in the normal sensory -environment
process?? -meds
-cognitive/emotional resources: attitudes, values, culture, intelligence level,
anxiety
-illness: injury, trauma, dz
-age: experiences, learned responses
vibratory sense ability to feel vibration sensation
ex: tested by striking a tuning fork and then placing the vibrating fork against a
bony prominence
kinesthetic awareness of body position and movement without seeing
ex: where's the L ft, typing on keyboard without looking at keys, riding a bicycle
, stereognosis awareness of object's shape, size, texture from touch
ex: pt has eyes closed & you put coin in their hand, paper clip, pens, pencils,
coins, erasers
visceral awareness of internal organs & sensation
ex: mechanical stimuli (prostaglandins, bradykinin, hydrogen & K+ compounds can
activate visceral nociceptors & produce pain)
how to assess and accurately document lOC & -see if pt is aware of person, place, & time (alert means pt readily responds to all
orientation stimuli appropriately)
-if pt correctly responds to all 3 (oriented X3)
-if not, specify how pt isn't oriented
clients at high risk for various sensory disturbances -pts with emotional disorders
-have limited social contact with family and friends (e.g., clients from a different
culture).
-clients who have brain damage or who are taking medications that affect the
central nervous system
-have pain or discomfort
-are acutely ill and have been admitted to an acute care facility
-are being closely monitored in an intensive care unit (ICU)
sensory deprivation level of sensory input is too LOW to permit normal function
(pt isn't getting enough sensory stimuli)
sensory deprivation causes/risk factors -restricting environment
-decreased input from impaired senses
-meaningless stimuli
-immobilized; isolation
-elderly
-confused
-terminated ill
-sensory deficit
sensory deprivation s/s -boredom
-restlessness
-decreased attn span
-emotional lability
-disorganized thought
-anxiety
-hallucinations
-increased sleep
-irritability
nursing interventions for sensory deprivation -increase stimuli; meaning
-visit more; orient frequently
-explain all care
-place TV, radio, clock, calendar in room
-display pics, cards, familiar objects
-touch more
-offer variety of foods
-elevate HOB; open door
-assist OOB; ambulate
