Chapter 49: Sensory Alterations
ra ra ra
MULTIPLE CHOICE ra
1. A nursing attendant is administering a vaccine to a child who is visually impaired. After the n
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eedle enters the arm, the child says, ―Ow, that was sharp!‖ What conclusion about the chil
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dar will the nursing attendant come to when interpreting the child’s response?
ra a. ra ra ra ra ra ra ra ra ra
Sensations are intact. ra ra
b. Reception is intact. ra ra
c. Perception is intact. ra ra
d. Reaction is intact. ra ra
ACCURATE ar
ANSWER:-C
When a person becomes conscious of a stimulus and receives the information, perception tak
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es place. Perception includes integration and interpretation of stimuli based on the person’s ex
ra ra ra ra ra ra ra ra ra ra ra ra ar
periences. Sensation is a general term that refers to awareness of sensory stimuli through the
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body’s sense mechanisms. Reception begins with stimulation of a nerve cell called a receptor,
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
which is usually for only one type of stimulus such as light, touch, taste, or sound.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
Reaction is how a person responds to a perceived stimulus.
ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Differentiate among the processes of reception, perception, and reaction to sensory stimuli. ra ra ra ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Physiological Adaptation ra ra
2. A nursing attendant is describing the transmission of sound to a hospital client . In which o
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
rder will the nursing attendant list the pathway of sound, beginning with the first structure
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
?
1. Eardrum
2. Perilymph
3. Oval window ra
4. Bony ossicles ra
5. Eighth cranial nerve ra ra
a. 1, 5, 2, 4, 3 ra ra ra ra
b. 1, 3, 4, 2, 5
rarar a
ra ra ra ra
c. 1, 2, 4, 5, 3 ra ra ra ra
d. 1, 4, 3, 2, 5
rarar a
ra ra ra ra
ACCURATE ar
ANSWER:-D
Vibration of the eardrum transmits through the bony ossicles. Vibrations at the oval windo
ra ra ra ra ra ra ra ra ra ra ra ra ra
w transmit in perilymph within the inner ear to stimulate hair cells that send impulses along
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
the eighth cranial nerve to the brain.
ar ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Differentiate among the processes of reception, perception, and reaction to sensory stimuli. ra ra ra ra ra ra ra ra ra ra ra ar
TOP:Teaching/Learning MSC: Health Promotion and Maintenance ra ra ra ra
,3. A nursing attendant is caring for a hospital client diagnosed with presbycusis. Whic
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h assessment finding indicates an adaptation to the sensory deficit?
ar ra ra ra ra ra ra ra ra
a. The hospital client frequently cleans out eyes with saline washes.
ra ra ra ra ra ra ra ra ra
b. The hospital client applies different spices during mealtime to food.
ra ra rara ra ra ra ra ra ra
c. The hospital client turns one ear toward the nursing attendant during conversation.
ra ra ra ra ra ra ra ra ra ra ra
d. The hospital client isolates self from social situations with groups of people.
ra ra ra ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-C ra
Presbycusis is impaired hearing due to the aging process. Adaptation for a sensory deficit indi
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
cates that the hospital client alters behavior to accommodate for the sensory deficit, such as t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
urning the unaffected ear toward the speaker. Cleaning the eye and applying spices to food wo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
uld not have an effect for a hospital client with presbycusis. Avoiding others because of a sens
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ory deficit is maladaptive.
ra ra ra
DIF:Understand (comprehension) ra
OBJ:Explain factors that influence sensory function. TOP:Assessment ra ra ra ra ra ar
MSC: Physiological Adaptation ra ra
4. The nursing attendant will be most concerned about the risk of malnutrition for
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a hospital client with which sensory deficit?
ar ra ra ra ra ra
a. Xerostomia
b. Dysequilibrium
c. Diabetic retinopathy ra
d. Peripheral neuropathy ra
ACCURATE ANSWER:-A ra
Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra a
rand can lead to nutritional problems. The other options do not address taste- or
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nutritionrelated concerns. Dysequilibrium is balance. Diabetic retinopathy affects vision. ra ra ra ra ra ra ra ra ar
Periphera
l neuropathy includes numbness and tingling of the affected areas and stumbling gait.
ra ra ra ra ra ra ra ra ra ra ra ar
DIF:Understand (comprehension) ra
OBJ:Explain factors that influence sensory function. TOP:Assessment ra ra ra ra ra ar
MSC: Basic Care and Comfort ra ra ra ra
5. A nursing attendant is caring for an older adult. Which sensory change will the nursing
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
attendant identify as normal during the assessment? a. Impaired night vision
ra ra ra ra ra ra ra ra
b. Difficulty hearing low pitch ra ra ra
c. Heightened sense of smell ra ra ra
d. Increased taste discrimination ra ra
ACCURATE ANSWER:-A ra
Night vision becomes impaired as physiological changes in the aging eye occur. Older adults los
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
e the ability to distinguish highpitched noises and consonants. Senses of smell and taste are also
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
decreased with aging. ra ra
DIF:Understand (comprehension) ra
OBJ:Explain factors that influence sensory function. TOP:Assessment ra ra ra ra ra ar MSC: ra
Health Promotion and Maintenance ra ra ra
, 6. A nursing attendant is caring for an olderadult hospital client
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who was in a motor vehicle accident because the hospital client thou
ra ra ra ra ra ar ra ra ra ra ra
ght the stoplight was green. The hospital client asks the nursing attendant ―Should I sto
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
p driving?‖ Which response by the nursing attendant is most therapeutic?
ra ra ra ra ra ra ra ra ra ra
a. ―Yes, you should stop driving. As you age, your cognitive function declines, and be
ra ra ra ra ra ra ra ra ra ra ra ra ar
coming confused puts everyone else on the road at risk.‖ ra ra ra ra ra ra ra ra ra
b. ―Yes, you should ask family members to drive you around from now on. Your ref ra ra ra ra ra ra ra ra ra ra ar ar ra ar
lex skills have declined so much you can’t avoid an accident.‖
ra ra ra ra ra ra ra ra ra ra
c. ―No, as you age, you lose the ability to see colors. You need to think about sto
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
plights in a new way. If the top is lit up, it means stop, and if the bottom is lit up,
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra
it means go.‖ ra ra
d. ―No, instead you should see your ophthalmologist and get some glasses to help y
ra ra ra ra ra ra ra ra ra ra ra ra ar
ou see better.‖ ra ra
ACCURATE ANSWER:-C ra
Part of the normal aging process is reduced ability to see colors. The nursing attendant should t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
each the hospital client new ways to adapt to this deficit. This hospital client ’s accident was n
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ot due to impaired cognitive function or reflexes. Glasses will not assist the hospital client in co
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
lor discrimination. ra
DIF:Analyze (analysis) ra
OBJ:Explain factors that influence sensory function. TOP:Implemen tation ra ra ra ra ra ar MSC:
Health Promotion and Maintenance ra ra ra
7. A hospital client who recently had a stroke is going to be discharged at the end of the week.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
The nursing attendant notices that the hospital client is having difficulty with communicat
ra ra ra ra ra ra ra ra ra ra ra ra
ion and becomes tearful at times. Which intervention will the nursing attendant include in
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
the hospital client ’s plan of care?
ra ra ra ra ra ra
a. Teach the hospital client about special assistive devices. ra ra ra ra ra ra ra
b. Make the hospital client talk as much as possible. ra ra ra ra ra ra ra ra
c. Obtain an order for antidepressant medications. ra ra ra ra ra
d. Place a consult for a home health nursing attendant . ra ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
Because a stroke often causes partial or complete paralysis of one side of a hospital client ’s bo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
dy, the hospital client needs special assistive devices. The nursing attendant should include int
ra ra ra ra ra ra ra ra ra ra ra ra ar
erventions that help the hospital client adapt to this deficit while maintaining independenc
ra ra ra ra ra r a ra ra ra ra ra ra
e. Teaching the hospital client
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to use assistive devices allows the hospital client to care for h im-
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or herself. Making the hospital client talk can be inappropriate and demeaning. A home healt
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
h nursing attendant is not necessary as long as the hospital client is able to care for him or herself
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
. Instead of placing the hospital client
ra on antidepressants, assist the hospital clien
ra ra ra ra ra r a ra ra ra ra ra
t in attempting to adapt behavior to the sensory deficit.
ra ra ra ra ra ra ra ra ra
DIF:Analyze (analysis) ra
OBJ:Use clinical judgment to plan and implement nursing interventions for hospital client s w
ra ra ra ra ra ra ra ra ra ra ra ra ra
it h sensory deficits, sensory deprivation, and sensory overload. TOP:Planning MSC:
ar ra ra ra ra ra ra ra
Basic Care and Comfort ra ra ra
8.
A hospital client has both hearing and visual sensory impairments. Which psychologica
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l n ursing diagnosis will the nursing attendant add to the care plan? a. Risk for falls
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ra ra ra
MULTIPLE CHOICE ra
1. A nursing attendant is administering a vaccine to a child who is visually impaired. After the n
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
eedle enters the arm, the child says, ―Ow, that was sharp!‖ What conclusion about the chil
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
dar will the nursing attendant come to when interpreting the child’s response?
ra a. ra ra ra ra ra ra ra ra ra
Sensations are intact. ra ra
b. Reception is intact. ra ra
c. Perception is intact. ra ra
d. Reaction is intact. ra ra
ACCURATE ar
ANSWER:-C
When a person becomes conscious of a stimulus and receives the information, perception tak
ra ra ra ra ra ra ra ra ra ra ra ra ra
es place. Perception includes integration and interpretation of stimuli based on the person’s ex
ra ra ra ra ra ra ra ra ra ra ra ra ar
periences. Sensation is a general term that refers to awareness of sensory stimuli through the
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
body’s sense mechanisms. Reception begins with stimulation of a nerve cell called a receptor,
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
which is usually for only one type of stimulus such as light, touch, taste, or sound.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
Reaction is how a person responds to a perceived stimulus.
ra ra ra ra ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Differentiate among the processes of reception, perception, and reaction to sensory stimuli. ra ra ra ra ra ra ra ra ra ra ra ar
TOP:Assessment MSC: Physiological Adaptation ra ra
2. A nursing attendant is describing the transmission of sound to a hospital client . In which o
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
rder will the nursing attendant list the pathway of sound, beginning with the first structure
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
?
1. Eardrum
2. Perilymph
3. Oval window ra
4. Bony ossicles ra
5. Eighth cranial nerve ra ra
a. 1, 5, 2, 4, 3 ra ra ra ra
b. 1, 3, 4, 2, 5
rarar a
ra ra ra ra
c. 1, 2, 4, 5, 3 ra ra ra ra
d. 1, 4, 3, 2, 5
rarar a
ra ra ra ra
ACCURATE ar
ANSWER:-D
Vibration of the eardrum transmits through the bony ossicles. Vibrations at the oval windo
ra ra ra ra ra ra ra ra ra ra ra ra ra
w transmit in perilymph within the inner ear to stimulate hair cells that send impulses along
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
the eighth cranial nerve to the brain.
ar ra ra ra ra ra
DIF:Understand (comprehension) ra
OBJ:Differentiate among the processes of reception, perception, and reaction to sensory stimuli. ra ra ra ra ra ra ra ra ra ra ra ar
TOP:Teaching/Learning MSC: Health Promotion and Maintenance ra ra ra ra
,3. A nursing attendant is caring for a hospital client diagnosed with presbycusis. Whic
ra ra ra ra ra ra ra ra ra ra ra ra
h assessment finding indicates an adaptation to the sensory deficit?
ar ra ra ra ra ra ra ra ra
a. The hospital client frequently cleans out eyes with saline washes.
ra ra ra ra ra ra ra ra ra
b. The hospital client applies different spices during mealtime to food.
ra ra rara ra ra ra ra ra ra
c. The hospital client turns one ear toward the nursing attendant during conversation.
ra ra ra ra ra ra ra ra ra ra ra
d. The hospital client isolates self from social situations with groups of people.
ra ra ra ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-C ra
Presbycusis is impaired hearing due to the aging process. Adaptation for a sensory deficit indi
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
cates that the hospital client alters behavior to accommodate for the sensory deficit, such as t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
urning the unaffected ear toward the speaker. Cleaning the eye and applying spices to food wo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
uld not have an effect for a hospital client with presbycusis. Avoiding others because of a sens
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ory deficit is maladaptive.
ra ra ra
DIF:Understand (comprehension) ra
OBJ:Explain factors that influence sensory function. TOP:Assessment ra ra ra ra ra ar
MSC: Physiological Adaptation ra ra
4. The nursing attendant will be most concerned about the risk of malnutrition for
ra ra ra ra ra ra ra ra ra ra ra ra ra
a hospital client with which sensory deficit?
ar ra ra ra ra ra
a. Xerostomia
b. Dysequilibrium
c. Diabetic retinopathy ra
d. Peripheral neuropathy ra
ACCURATE ANSWER:-A ra
Xerostomia is a decrease in production of saliva; this decreases the ability and desire to eat
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra a
rand can lead to nutritional problems. The other options do not address taste- or
ra ra ra ra ra ra ra ra ra ra ra ra ra
nutritionrelated concerns. Dysequilibrium is balance. Diabetic retinopathy affects vision. ra ra ra ra ra ra ra ra ar
Periphera
l neuropathy includes numbness and tingling of the affected areas and stumbling gait.
ra ra ra ra ra ra ra ra ra ra ra ar
DIF:Understand (comprehension) ra
OBJ:Explain factors that influence sensory function. TOP:Assessment ra ra ra ra ra ar
MSC: Basic Care and Comfort ra ra ra ra
5. A nursing attendant is caring for an older adult. Which sensory change will the nursing
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
attendant identify as normal during the assessment? a. Impaired night vision
ra ra ra ra ra ra ra ra
b. Difficulty hearing low pitch ra ra ra
c. Heightened sense of smell ra ra ra
d. Increased taste discrimination ra ra
ACCURATE ANSWER:-A ra
Night vision becomes impaired as physiological changes in the aging eye occur. Older adults los
ra ra ra ra ra ra ra ra ra ra ra ra ra ar
e the ability to distinguish highpitched noises and consonants. Senses of smell and taste are also
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
decreased with aging. ra ra
DIF:Understand (comprehension) ra
OBJ:Explain factors that influence sensory function. TOP:Assessment ra ra ra ra ra ar MSC: ra
Health Promotion and Maintenance ra ra ra
, 6. A nursing attendant is caring for an olderadult hospital client
ra ra ra ra ra ra ra ra ra ra
who was in a motor vehicle accident because the hospital client thou
ra ra ra ra ra ar ra ra ra ra ra
ght the stoplight was green. The hospital client asks the nursing attendant ―Should I sto
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
p driving?‖ Which response by the nursing attendant is most therapeutic?
ra ra ra ra ra ra ra ra ra ra
a. ―Yes, you should stop driving. As you age, your cognitive function declines, and be
ra ra ra ra ra ra ra ra ra ra ra ra ar
coming confused puts everyone else on the road at risk.‖ ra ra ra ra ra ra ra ra ra
b. ―Yes, you should ask family members to drive you around from now on. Your ref ra ra ra ra ra ra ra ra ra ra ar ar ra ar
lex skills have declined so much you can’t avoid an accident.‖
ra ra ra ra ra ra ra ra ra ra
c. ―No, as you age, you lose the ability to see colors. You need to think about sto
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
plights in a new way. If the top is lit up, it means stop, and if the bottom is lit up,
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar ra
it means go.‖ ra ra
d. ―No, instead you should see your ophthalmologist and get some glasses to help y
ra ra ra ra ra ra ra ra ra ra ra ra ar
ou see better.‖ ra ra
ACCURATE ANSWER:-C ra
Part of the normal aging process is reduced ability to see colors. The nursing attendant should t
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
each the hospital client new ways to adapt to this deficit. This hospital client ’s accident was n
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
ot due to impaired cognitive function or reflexes. Glasses will not assist the hospital client in co
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
lor discrimination. ra
DIF:Analyze (analysis) ra
OBJ:Explain factors that influence sensory function. TOP:Implemen tation ra ra ra ra ra ar MSC:
Health Promotion and Maintenance ra ra ra
7. A hospital client who recently had a stroke is going to be discharged at the end of the week.
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ar
The nursing attendant notices that the hospital client is having difficulty with communicat
ra ra ra ra ra ra ra ra ra ra ra ra
ion and becomes tearful at times. Which intervention will the nursing attendant include in
ra ra ra ra ra ra ra ra ra ra ra ra ra ra
the hospital client ’s plan of care?
ra ra ra ra ra ra
a. Teach the hospital client about special assistive devices. ra ra ra ra ra ra ra
b. Make the hospital client talk as much as possible. ra ra ra ra ra ra ra ra
c. Obtain an order for antidepressant medications. ra ra ra ra ra
d. Place a consult for a home health nursing attendant . ra ra ra ra ra ra ra ra ra
ACCURATE ANSWER:-A ra
Because a stroke often causes partial or complete paralysis of one side of a hospital client ’s bo
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
dy, the hospital client needs special assistive devices. The nursing attendant should include int
ra ra ra ra ra ra ra ra ra ra ra ra ar
erventions that help the hospital client adapt to this deficit while maintaining independenc
ra ra ra ra ra r a ra ra ra ra ra ra
e. Teaching the hospital client
ra ra ra ra r a
to use assistive devices allows the hospital client to care for h im-
ra ra ra ra ra ra ra ra ra ra ra
or herself. Making the hospital client talk can be inappropriate and demeaning. A home healt
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
h nursing attendant is not necessary as long as the hospital client is able to care for him or herself
ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra ra
. Instead of placing the hospital client
ra on antidepressants, assist the hospital clien
ra ra ra ra ra r a ra ra ra ra ra
t in attempting to adapt behavior to the sensory deficit.
ra ra ra ra ra ra ra ra ra
DIF:Analyze (analysis) ra
OBJ:Use clinical judgment to plan and implement nursing interventions for hospital client s w
ra ra ra ra ra ra ra ra ra ra ra ra ra
it h sensory deficits, sensory deprivation, and sensory overload. TOP:Planning MSC:
ar ra ra ra ra ra ra ra
Basic Care and Comfort ra ra ra
8.
A hospital client has both hearing and visual sensory impairments. Which psychologica
ra ra ra ra ra ra ra ra ra ra ra
l n ursing diagnosis will the nursing attendant add to the care plan? a. Risk for falls
ar ra ra ra ra ra ra ra ra ra ra ra ra
