C HAPTER 49: S ENSORY A LTERATIONS
Fundamentals of Nursing 10th Edition; Pot ter Perry
MULTIPLE CHOICE
1. The nurse is visiting the day care cent er for routine assessment of the
children. After spending time with the children in one of the playrooms,
the nurse suspects that a child has a visual deficit as a result of observing:
A. Poor balance and gait
B. An increase in weight
C. Sitting and rocking back an d forth
D. A failure to respond when touched
ANS: C
Behaviors of children indicating a possible visual deficit include self -
stimulation such as eye rubbing, body rocking, sniffing or smelling,
and arm twirling. Poor balance and gait may indicate an impairme nt of
position sense in the adult. A weight change may indicate a deficit in
taste in the adult. Failure to respond to touch may indicate a touch
deficit in the adult.
DIF: A REF: 1350 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Psychosocial Integrity/Sensory/Perceptual Alterations S ystems
,2. A client has been in the intensive care unit for 4 days and has begun to
show signs of restlessness and anxiet y even though the client has been
reassured that his or her condi tion is improving and discharge to the unit
will be occurring soon. The cause of the clients emotional state is a result
of:
A. Fear of death
B. Social isolation
C. Sensory overload
D. Anxiet y disorder
ANS: C
The acutel y ill client easil y falls victim to sensory ove rload. The client
in constant pain or who undergoes frequent monitoring of vital signs or
who has irritation from drainage tubes is at risk.
DIF: A REF: 1345 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Psychosocial Integrity/Sensory/Perceptual Alterations S ystems
3. A client has been in the intensive care unit for 4 days and has begun to
show signs of restlessness and anxiet y, and the nurse believes the client is
experiencing sensory overload. Which of the followin g interventions will
be most therapeutic in assisting the client?
A. Limiting interaction with the client to the safe minimum
B. Moving the client to a space furthest from the nursing station
C. Keeping the clients lights dimmed and curtains partiall y drawn
D. Asking the clients health care provider to consider earl y discharge
to the unit
, ANS: C
Constant reorientation and control of excessive stimuli becomes an
important part of the clients care. Although the remaining options may
have value, they are not the most th erapeutic because external
stimulation is the most likel y cause of the problem.
DIF: C REF: 1345 OBJ: Anal ysis TOP: Nursing Process:
Planning MSC: NC LEX test plan designation: Psychosocial
Integrit y/Sensory/Perceptual Alterations Systems
4. The wife of a 70-year-old client who is recuperating at home from hip
replacement surgery expresses a concern to the nurse that He must be
getting depressed. He just doesnt interact with people like he used to.
Which of the following is the nurses most therapeutic respo nse?
A. Are there any other signs of depressions?
B. Does he usuall y enjoy interacting with visitors?
C. Do you think he may be having difficult y hearing what people are
saying to him?
D. Well he could be. Do you want me to see if his health care provider
will order an antidepressant?
ANS: C
A concern with normal age -related sensory changes is that older adults
with a deficit are sometimes inappropriatel y diagnosed with dementia
or depression. The remaining options assume that depression may be
the cause of his perso nalit y change.
, DIF: C REF: 1345 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Psychosocial
Integrit y/Sensory/Perceptual Alterations Systems
5. A 54-year-old client expresses concern about her weakening sense of
smell to the nurse during an admission interview. The nurses most
therapeutic response is:
A. I don’t think it is anything to worry about, but you could mention it
to your health care provider
B. That is reall y a fairly common complaint of people your age; I don ’t
think there is anything to worry about
C. As long as you can smell things like smoke if there is a fire, I think
it is something you need to get used to
D. As long as you can smell things like smoke if there is a fire, I think
it is something you need to get used to
ANS: D
Gustatory and olfactory changes begin around age 50 and include a
decrease in the number of taste buds and a decrease in the number of
sensory cells in the nasal lining. Reduced taste discrimination and
reduced sensitivit y to odors are common. The remaining options do not
provide the most likely cause of the sensory deficit.
DIF: C REF: 1345 -1346 OBJ: Anal ysis TOP: Nursing
Process: Implementation MSC: NC LEX test plan
designation: Psychosocial Integrit y/Sensory/Perceptual
Alterations S ystems
Fundamentals of Nursing 10th Edition; Pot ter Perry
MULTIPLE CHOICE
1. The nurse is visiting the day care cent er for routine assessment of the
children. After spending time with the children in one of the playrooms,
the nurse suspects that a child has a visual deficit as a result of observing:
A. Poor balance and gait
B. An increase in weight
C. Sitting and rocking back an d forth
D. A failure to respond when touched
ANS: C
Behaviors of children indicating a possible visual deficit include self -
stimulation such as eye rubbing, body rocking, sniffing or smelling,
and arm twirling. Poor balance and gait may indicate an impairme nt of
position sense in the adult. A weight change may indicate a deficit in
taste in the adult. Failure to respond to touch may indicate a touch
deficit in the adult.
DIF: A REF: 1350 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Psychosocial Integrity/Sensory/Perceptual Alterations S ystems
,2. A client has been in the intensive care unit for 4 days and has begun to
show signs of restlessness and anxiet y even though the client has been
reassured that his or her condi tion is improving and discharge to the unit
will be occurring soon. The cause of the clients emotional state is a result
of:
A. Fear of death
B. Social isolation
C. Sensory overload
D. Anxiet y disorder
ANS: C
The acutel y ill client easil y falls victim to sensory ove rload. The client
in constant pain or who undergoes frequent monitoring of vital signs or
who has irritation from drainage tubes is at risk.
DIF: A REF: 1345 OBJ: Comprehension TOP: Nursing
Process: Assessment MSC: NC LEX test plan designation:
Psychosocial Integrity/Sensory/Perceptual Alterations S ystems
3. A client has been in the intensive care unit for 4 days and has begun to
show signs of restlessness and anxiet y, and the nurse believes the client is
experiencing sensory overload. Which of the followin g interventions will
be most therapeutic in assisting the client?
A. Limiting interaction with the client to the safe minimum
B. Moving the client to a space furthest from the nursing station
C. Keeping the clients lights dimmed and curtains partiall y drawn
D. Asking the clients health care provider to consider earl y discharge
to the unit
, ANS: C
Constant reorientation and control of excessive stimuli becomes an
important part of the clients care. Although the remaining options may
have value, they are not the most th erapeutic because external
stimulation is the most likel y cause of the problem.
DIF: C REF: 1345 OBJ: Anal ysis TOP: Nursing Process:
Planning MSC: NC LEX test plan designation: Psychosocial
Integrit y/Sensory/Perceptual Alterations Systems
4. The wife of a 70-year-old client who is recuperating at home from hip
replacement surgery expresses a concern to the nurse that He must be
getting depressed. He just doesnt interact with people like he used to.
Which of the following is the nurses most therapeutic respo nse?
A. Are there any other signs of depressions?
B. Does he usuall y enjoy interacting with visitors?
C. Do you think he may be having difficult y hearing what people are
saying to him?
D. Well he could be. Do you want me to see if his health care provider
will order an antidepressant?
ANS: C
A concern with normal age -related sensory changes is that older adults
with a deficit are sometimes inappropriatel y diagnosed with dementia
or depression. The remaining options assume that depression may be
the cause of his perso nalit y change.
, DIF: C REF: 1345 OBJ: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Psychosocial
Integrit y/Sensory/Perceptual Alterations Systems
5. A 54-year-old client expresses concern about her weakening sense of
smell to the nurse during an admission interview. The nurses most
therapeutic response is:
A. I don’t think it is anything to worry about, but you could mention it
to your health care provider
B. That is reall y a fairly common complaint of people your age; I don ’t
think there is anything to worry about
C. As long as you can smell things like smoke if there is a fire, I think
it is something you need to get used to
D. As long as you can smell things like smoke if there is a fire, I think
it is something you need to get used to
ANS: D
Gustatory and olfactory changes begin around age 50 and include a
decrease in the number of taste buds and a decrease in the number of
sensory cells in the nasal lining. Reduced taste discrimination and
reduced sensitivit y to odors are common. The remaining options do not
provide the most likely cause of the sensory deficit.
DIF: C REF: 1345 -1346 OBJ: Anal ysis TOP: Nursing
Process: Implementation MSC: NC LEX test plan
designation: Psychosocial Integrit y/Sensory/Perceptual
Alterations S ystems
