Chapter 49 Sensory Alterations Fundamentals of Nursing 11th Edition (Potter & Perry) 50 NCLEX-Style Exam Questions with Detailed Rationales

1. A nurse is caring for a patient with expressive aphasia. What is the most appropriate nursing intervention? A) Speak loudly and slowly B) Use visual aids and gestures C) Encourage the patient to speak more D) Provide written materials only Answer: B Rationale: Expressive aphasia impairs verbal expression. Gestures and visual aids support communication. ________________________________________ 2. A patient is newly diagnosed with presbycusis. What nursing action is most effective? A) Speak in a high-pitched voice B) Use exaggerated lip movements C) Speak clearly at a moderate pace D) Stand behind the patient when talking Answer: C Rationale: Patients with presbycusis benefit from clear, moderate speech in a low tone with direct eye contact. ________________________________________ 3. Which of the following is a priority safety concern for a patient with peripheral neuropathy? A) Social isolation B) Skin breakdown from immobility C) Increased risk of foot injury D) Risk for impaired memory Answer: C Rationale: Loss of sensation in the extremities increases the risk of unnoticed foot injuries. ________________________________________ 4. What sensory deficit is most commonly associated with aging? A) Tinnitus B) Cataracts C) Presbyopia D) Glaucoma Answer: C Rationale: Presbyopia is age-related farsightedness that impairs near vision, common after age 40. ________________________________________ 5. When planning care for a patient with sensory deprivation, which intervention is most appropriate? A) Provide a dark, quiet room B) Limit visitors to reduce overstimulation C) Encourage the use of clocks and calendars D) Reduce conversation to prevent confusion Answer: C Rationale: Sensory deprivation can lead to disorientation; clocks and calendars promote orientation and cognitive stimulation. ________________________________________ 6. A patient who has been isolated for infection control becomes irritable and withdrawn. What should the nurse suspect? A) Delirium B) Sensory overload C) Sensory deprivation D) Depression Answer: C Rationale: Isolation can cause sensory deprivation, leading to mood changes and withdrawal. ________________________________________ 7. Which assessment finding indicates that a patient may be experiencing sensory overload? A) Sleeping for prolonged periods B) Disorientation and confusion C) Refusal to wear eyeglasses D) Reduced verbal communication Answer: B Rationale: Sensory overload results in disorientation due to excessive stimuli. ________________________________________ 8. A nurse places a sign on a patient’s door that reads “Hearing Impaired.” What is the rationale for this? A) To notify the family of the condition B) To instruct staff to avoid unnecessary noise C) To facilitate communication adjustments by staff D) To limit patient stimulation Answer: C Rationale: The sign helps staff recognize the need to adjust communication strategies for the patient. ________________________________________ 9. The nurse is caring for a patient with glaucoma. Which statement by the patient requires further teaching? A) “I will take my eye drops as prescribed.” B) “I understand my vision loss may not be reversible.” C) “I need to avoid activities that increase eye pressure.” D) “This condition will go away with time.” Answer: D Rationale: Glaucoma is a chronic condition requiring lifelong treatment to manage, not cure.