NSC 114 Exam #4 Questions And Answers All Correct Graded A+

visual - correct answers having to do with sight or seeing auditory - correct answers Having to do with the sense of hearing olfactory - correct answers relating to the sense of smell tactile - correct answers relating to the sense of touch gustatory - correct answers relating to the sense of taste Kinesthetic - correct answers refers to awareness of the position and movement of body parts Stereognosis - correct answers Ability to perceive and understand an object through touch by its size, shape, and texture visceral - correct answers refers to any large organ of the body; internal organs produce stimuli that make a person aware of them (full stomach) sensory perception - correct answers involves the conscious organization and translation of the data or stimuli into meaningful information Stimulus - correct answers a signal to which an organism responds agent or act that stimulates a nerve receptor Receptor - correct answers - a nerve cell acts as a receptor by converting the stimulus to a nerve impulse - most receptors are specific; sensitive to only one type of stimulus - visual, auditory, touch Impulse conduction - correct answers the impulse travels along nerve pathways to the spinal cord or directly to the brain ex. auditory impulses travel to the organ of Corti in the nerve to the temporal lobe of the brain Perception - correct answers perception, or awareness and interpretation of stimuli, takes place in the brain, where specialized brain cells interpret the nature and quality of the sensory stimuli. the client's level of consciousness affects the perception of the stimuli Arousal Mechanism - correct answers - Brain must be alert to receive and interpret data/stimuli - Mediated by the reticular activating system (RAS) Reticular Activating System (RAS) - correct answers a dense network of neurons found in the core of the brain stem; it arouses the cortex and screens incoming information - two components 1. REA = reticular excitatory area; responsible for arousal and wakefulness 2. RIA = reticular inhibitory States of Awareness - correct answers - Full consciousness= alert; oriented to time, place, person, understands verbal and written words - Disoriented= Not oriented to time, place, or person - Confused= Reduced awareness, easily bewildered; poor memory, misinterprets stimuli; impaired judgement - Somnolent= Extreme drowsiness but will respond to stimuli - Semi-comatose= Can be aroused by extreme or repeated stimuli - Coma= Will not respond to verbal stimuli factors influencing sensory function - correct answers •Developmental stage •Culture - child in a big city; sudden change •Level of stress •Medications and illness •Lifestyle Clinical Manifestations of sensory deprivation - correct answers - Excessive yawning, drowsiness, and sleeping • Decreased attention span, difficulty concentrating, and decreased problem solving • Impaired memory; periodic disorientation, general confusion, or nocturnal confusion • Preoccupation with somatic complaints, such as palpitations • Hallucinations or delusions • Crying, annoyance over small matters and depression • Apathy and emotional liability Sensory Alterations - correct answers Sensory deficits sensory deprivation sensory overload Clinical Manifestations of sensory overload and definition - correct answers Generally occurs when a person is unable to process or manage the amount or intensity of sensory stimuli Complaints of fatigue, sleeplessness Irritability, anxiety, and restlessness Periodic or general disorientation Reduced problem-solving ability and task performance Increased muscle tension Scattered attention and racing thoughts sensory deficits - correct answers impaired or absent functioning of one or more senses ex. blindness, deafness sensory deprivation - correct answers -impaired reception, perception or both -usually can adapt if loss is gradual -sudden loss is disorienting -deficit can lead to both sensory deprivation and sensory overload assessing sensory perception function - correct answers - nursing history - mental status examination - physical examination - identification of clients at risk - client's environment - social support network clients at risk for sensory deprivation - correct answers - non-stimulating or monotonous environment - impaired vision or hearing - mobility restrictions - inability to process stimuli - emotional disorders - limited social contact Clients at risk for sensory overload - correct answers - pain or discomfort - admission to an acute care facility - monitoring in intensive care units - invasive tubes - decreased cognitive ability NANDAs for sensory perception - correct answers - acute confusion - chronic confusion - impaired memory - risk for acute confusion planning and outcome criteria for sensory perception - correct answers - prevent injury - maintain function of existing senses - develop an effective communication mechanism - prevent sensory overload or deprivation - reduce social isolation - perform ADLs independently and safely Implementing for sensory perception - correct answers - promote health sensory function - early detection, screening - approapriate sensory input - visual impairment associated with greater difficulty in performing ADLs - hearing impairment requires substituting visual cues to signal danger; allow more time for processing in older adults - impaired smell requires caution with an around chemicals, food - impaired touch can lead to burns or pressure ulcers; test water with thermometer; change position often macular degeneration - correct answers breakdown or thinning of the tissues in the macula, resulting in partial or complete loss of central vision loss of central vision cataract - correct answers clouding of the lens of the eye Glaucoma - correct answers - A group of eye conditions that damage the optic nerve (vital for good vision) - Caused most of the time by high pressure in your eye - leading causes of blindness for people over the age of 60 Normal eye pressure (intraocular pressure) - correct answers 10-21 mmHg whisper test - correct answers - A hearing test in which the examiner stands 28-24 inches from one of the patient's ears, has the person block sound in one ear and whispers a random set of 3 numbers and letters (or three non-related words) into the other ear, asking the person to repeat what was heard. - Test in which an examiner whispers a sentence and asks the patient to repeat it to evaluate loss of high-frequency sounds - tests Auditory Nerve Snellen chart - correct answers chart containing symbols that is used in the testing of visual acuity/the sharpness of visual discrimination Weber test - correct answers test for sensorineural hearing loss If the hearing loss is conductive, the sound will be heard best in the affected ear. If the loss is sensorineural, the sound will be heard best in the normal ear. Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard. Rinne test - correct answers hearing acuity test performed with a vibrating tuning fork that is first placed on the mastoid process and then in front of the external auditory canal to test bone and air conduction test for conductive hearing loss If the hearing loss is conductive, the sound will be heard best in the affected ear. If the loss is sensorineural, the sound will be heard best in the normal ear. assessing olfactory sense - correct answers ask client to identify specific aromas assessing gustatory sense - correct answers ask the client to identify three tastes such as lemon, salt, and sugar sweet, sour, salty assessing tactile sense - correct answers testing light touch sharp and dull sensation two point discrimination hot and cold sensation vibration sense self concept - correct answers - mental image of oneself