NURSING TEST BANK-CH.31
SENSORY PERCEPTION
The nurse checks a patients pupils using a penlight. Which receptors is the nurse
stimulating?
1) Chemoreceptors
2) Photoreceptors
3) Proprioceptors
4) Mechanoreceptors - ANS>>2) Photoreceptors
Photoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the
skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an
individual to sense the position of the body in space. Chemoreceptors are located in the
taste buds and epithelium of the nasal cavity. They play a role in taste and smell.
Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the
skin and hair follicles detect touch, pressure, and vibration.
Which structure within the brain is responsible for consciousness and alertness?
1) Reticular activating system
2) Cerebellum
3) Thalamus
4) Hypothalamus - ANS>>1) Reticular activating system
The reticular activating system, located in the brainstem, controls consciousness and
alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and
controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus
controls body temperature.
The nurse has been teaching a parent about stimuli to develop her infants auditory
nervous system. Which behavior by a parent toward the child provides evidence that
learning occurred?
1) Cuddling
2) Speaking
3) Feeding
4) Soothing - ANS>>2) Speaking
Exposure to voices, music, and ambient sound helps develop the infants auditory
nervous system. Cuddling, feeding, and soothing provide comfort and pleasure and
teach the infant about his external environment.
A patient complains to the nurse that since taking a medication he has suffered from
excessively dry mouth. What term should the nurse use to document this complaint?
1) Exophthalmos
, 2) Anosmia
3) Insomnia
4) Xerostomia - ANS>>4) Xerostomia
The nurse should document excessively dry mouth as xerostomia. Exophthalmos is
abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosmia is
losing the sense of smell. Insomnia is inability to sleep.
Which nursing diagnosis has the highest priority for a patient with impaired tactile
perception?
1) Self-Care Deficit: Dressing and Grooming
2) Impaired Adjustment
3) Risk for Injury
4) Activity Intolerance - ANS>>3) Risk for Injury
The patient with impaired tactile perception is unable to perceive touch, pressure, heat,
cold, or pain, placing him at risk for injury. Self-Care Deficit, Impaired Adjustment, and
Activity Intolerance are also likely to be appropriate for this patient but are not as high a
priority as Risk for Injury. Risk for Injury is directly related to safety, which must always
be a priority.
A patient with Parkinsons disease is at risk for which complication?
1) Impaired kinesthesia
2) Macular degeneration
3) Seizures
4) Xerostomia - ANS>>1) Impaired kinesthesia
Patients with Parkinsons disease are at risk for impaired kinesthesia, placing them at
risk for falling. Drooling, not excessive dry mouth (xerostomia), is common with
Parkinsons disease. Seizures and macular degeneration are not associated with
Parkinsons disease.
The nurse is caring for a patient with dementia who becomes agitated every evening.
Which intervention by the nurse is best for calming this patient?
1) Encouraging family members to visit only during the day
2) Applying wrist restraints during periods of agitation
3) Playing soft, calming music during the evening
4) Administering lorazepam (a tranquilizer) - ANS>>3) Playing soft, calming music
during the evening
Soft, calming music is sometimes helpful for patients with dementia. Encouraging a
family member to sit with the patient might have a calming effect, but the option does
not provide for that during the evening when the patient is symptomatic. Applying
bilateral wrist restraints might further agitate the patient. Lorazepam will provide
sedation but might cause further confusion.
SENSORY PERCEPTION
The nurse checks a patients pupils using a penlight. Which receptors is the nurse
stimulating?
1) Chemoreceptors
2) Photoreceptors
3) Proprioceptors
4) Mechanoreceptors - ANS>>2) Photoreceptors
Photoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the
skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an
individual to sense the position of the body in space. Chemoreceptors are located in the
taste buds and epithelium of the nasal cavity. They play a role in taste and smell.
Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the
skin and hair follicles detect touch, pressure, and vibration.
Which structure within the brain is responsible for consciousness and alertness?
1) Reticular activating system
2) Cerebellum
3) Thalamus
4) Hypothalamus - ANS>>1) Reticular activating system
The reticular activating system, located in the brainstem, controls consciousness and
alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and
controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus
controls body temperature.
The nurse has been teaching a parent about stimuli to develop her infants auditory
nervous system. Which behavior by a parent toward the child provides evidence that
learning occurred?
1) Cuddling
2) Speaking
3) Feeding
4) Soothing - ANS>>2) Speaking
Exposure to voices, music, and ambient sound helps develop the infants auditory
nervous system. Cuddling, feeding, and soothing provide comfort and pleasure and
teach the infant about his external environment.
A patient complains to the nurse that since taking a medication he has suffered from
excessively dry mouth. What term should the nurse use to document this complaint?
1) Exophthalmos
, 2) Anosmia
3) Insomnia
4) Xerostomia - ANS>>4) Xerostomia
The nurse should document excessively dry mouth as xerostomia. Exophthalmos is
abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosmia is
losing the sense of smell. Insomnia is inability to sleep.
Which nursing diagnosis has the highest priority for a patient with impaired tactile
perception?
1) Self-Care Deficit: Dressing and Grooming
2) Impaired Adjustment
3) Risk for Injury
4) Activity Intolerance - ANS>>3) Risk for Injury
The patient with impaired tactile perception is unable to perceive touch, pressure, heat,
cold, or pain, placing him at risk for injury. Self-Care Deficit, Impaired Adjustment, and
Activity Intolerance are also likely to be appropriate for this patient but are not as high a
priority as Risk for Injury. Risk for Injury is directly related to safety, which must always
be a priority.
A patient with Parkinsons disease is at risk for which complication?
1) Impaired kinesthesia
2) Macular degeneration
3) Seizures
4) Xerostomia - ANS>>1) Impaired kinesthesia
Patients with Parkinsons disease are at risk for impaired kinesthesia, placing them at
risk for falling. Drooling, not excessive dry mouth (xerostomia), is common with
Parkinsons disease. Seizures and macular degeneration are not associated with
Parkinsons disease.
The nurse is caring for a patient with dementia who becomes agitated every evening.
Which intervention by the nurse is best for calming this patient?
1) Encouraging family members to visit only during the day
2) Applying wrist restraints during periods of agitation
3) Playing soft, calming music during the evening
4) Administering lorazepam (a tranquilizer) - ANS>>3) Playing soft, calming music
during the evening
Soft, calming music is sometimes helpful for patients with dementia. Encouraging a
family member to sit with the patient might have a calming effect, but the option does
not provide for that during the evening when the patient is symptomatic. Applying
bilateral wrist restraints might further agitate the patient. Lorazepam will provide
sedation but might cause further confusion.
