sensory and perception fundamental of nursing
A 74-year-old client is hospitalized with acute onset delirium of unknown etiology. The nurse questions the family and asks
what has changed recently. Which responses made by the family could have contributed to the delirium? Select all that
apply.
Bipolar disorder
New medication
Electrolyte imbalance
Urinary tract infection
Physical changes in the brain - ANS -New medication
Electrolyte imbalance
Urinary tract infection
\The home health nurse enters the apartment of an elderly client who lives alone and immediately determines the client
has a hearing impairment. Which finding supports this conclusion?
The house has all the lights on in every room.
The television is on very loud in the same room as the client.
There is a magnifying glass laying on the bedside table.
The nurse spots assistive devices such as a wheeled walker. - ANS -The television is on very loud in the same room as
the client.
\The nurse enters a room and notes the client's eyes are closed. The nurse says the client's name without response.
What should be the nurse's next action?
Touch the client.
Call a Code Blue.
Perform a sternal rub.
, Obtain an interpreter. - ANS -Touch the client
\The nurse is caring for a client with osteomyelitis who is diagnosed with hearing loss related to long-term medication use.
Which medication may have caused this sensory loss?
Lisinopril (Zestril)
Vinblastine (Velban)
Atorvastatin (Lipitor)
Gentamicin (Garamycin) - ANS -Gentamicin (Garamycin)
\The nurse is developing a plan of care for a client with new hearing aids. Which long-term goal is most appropriate for the
client?
The client will wear the hearing aids 90% of the time.
The client will demonstrate successful insertion of the hearing aids.
The client will verbalize an understanding of the need for hearing aids.
The client will demonstrate how to properly care for the hearing aids within 2 weeks. - ANS -The client will demonstrate
how to properly care for the hearing aids within 2 weeks.
\The nurse is speaking with a client who is confused and is getting agitated. Which communication technique is most
appropriate when the client asks about the whereabouts of his or her spouse who has been deceased for 3 years?
"Your husband is not here."
"You must miss your husband."
"Your spouse passed away 3 years ago."
"Why do you keep asking for your spouse? You know your spouse isn't here." - ANS -you must miss your husband
\The nurse is working with the family members who reports their elderly parent has decreased visual and hearing acuity.
Which clinical manifestations should the nurse instruct the family to report? Select all that apply.
Withdrawal
Depression
Aggression
Combative
A 74-year-old client is hospitalized with acute onset delirium of unknown etiology. The nurse questions the family and asks
what has changed recently. Which responses made by the family could have contributed to the delirium? Select all that
apply.
Bipolar disorder
New medication
Electrolyte imbalance
Urinary tract infection
Physical changes in the brain - ANS -New medication
Electrolyte imbalance
Urinary tract infection
\The home health nurse enters the apartment of an elderly client who lives alone and immediately determines the client
has a hearing impairment. Which finding supports this conclusion?
The house has all the lights on in every room.
The television is on very loud in the same room as the client.
There is a magnifying glass laying on the bedside table.
The nurse spots assistive devices such as a wheeled walker. - ANS -The television is on very loud in the same room as
the client.
\The nurse enters a room and notes the client's eyes are closed. The nurse says the client's name without response.
What should be the nurse's next action?
Touch the client.
Call a Code Blue.
Perform a sternal rub.
, Obtain an interpreter. - ANS -Touch the client
\The nurse is caring for a client with osteomyelitis who is diagnosed with hearing loss related to long-term medication use.
Which medication may have caused this sensory loss?
Lisinopril (Zestril)
Vinblastine (Velban)
Atorvastatin (Lipitor)
Gentamicin (Garamycin) - ANS -Gentamicin (Garamycin)
\The nurse is developing a plan of care for a client with new hearing aids. Which long-term goal is most appropriate for the
client?
The client will wear the hearing aids 90% of the time.
The client will demonstrate successful insertion of the hearing aids.
The client will verbalize an understanding of the need for hearing aids.
The client will demonstrate how to properly care for the hearing aids within 2 weeks. - ANS -The client will demonstrate
how to properly care for the hearing aids within 2 weeks.
\The nurse is speaking with a client who is confused and is getting agitated. Which communication technique is most
appropriate when the client asks about the whereabouts of his or her spouse who has been deceased for 3 years?
"Your husband is not here."
"You must miss your husband."
"Your spouse passed away 3 years ago."
"Why do you keep asking for your spouse? You know your spouse isn't here." - ANS -you must miss your husband
\The nurse is working with the family members who reports their elderly parent has decreased visual and hearing acuity.
Which clinical manifestations should the nurse instruct the family to report? Select all that apply.
Withdrawal
Depression
Aggression
Combative
