Sensory Alterations

1.A 63-year-old welder who has gone to the clinic for an annual checkup. The patient shares a concern regarding difficulty hearing conversations at the coffee shop in the mornings. After looking in his ears to determine if there is a build-up of cerumen, the nurse tells the patient that the hearing loss may be associated with his occupation or it may be associated with aging. The nurse is aware that hearing loss associated with the aging process is known as which of the following?

a.
Tinnitus
b.
Ménière’s disease
c.
Presbycusis
d.
Presbyopia

ANS: C

Hearing changes often associated with aging include decreased hearing acuity, speech intelligibility, and pitch discrimination, which is referred to as presbycusis. Low-pitched sounds are easiest to hear, but it is difficult to hear conversation over background noise. A decrease in active sebaceous glands causes the cerumen to become dry and completely obstruct the external auditory canal. Tinnitus is commonly caused by ototoxicity and patients experience the sensation of ringing in the ears. Presbyopia refers to the gradual decline in ability of the lens to accommodate or focus on close objects and reduces ability to see near objects clearly. Although the cause of Ménière’s disease is unknown the symptoms include progressive low-frequency hearing loss, vertigo, tinnitus, and a full feeling or pressure in the affected ear.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 1113 | 1114 OBJ: Discuss common sensory changes that occur with aging.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

2.A 64-year-old house painter who is seeing his health care provider for his annual checkup. When the nurse asks the patient if they have any health concerns, the patient states, “I don’t think my vision is as good as it used to be, things look more yellow than they used to.” The nurse knows that this is a visual change in older adults caused by which of the following?

a.
Iris yellows
b.
Lens yellows
c.
Retina is hypersensitive
d.
Need for less light to see than when they were in young adulthood

ANS: B

Visual changes often include reduced visual fields, increased glare sensitivity, impaired night vision, reduced accommodation, reduced depth perception, and reduced color discrimination. Many of these symptoms occur because the pupils in the older adult take longer to dilate and constrict secondary to weaker iris muscles. Color vision decreases because the retina is duller and the lens yellows. Eventually, older adults may require three times as much light to see things as they did when they were in young adulthood.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1113 OBJ: Discuss common sensory changes that occur with aging.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

3.A family member is accompanying the elderly patient to their follow-up appointment after a recent hospitalization for gastrointestinal problems. The nurse interrupts a discussion between the family member and the patient regarding rancid food in the patient’s refrigerator. The family member looks at the nurse and states, “She was trying to eat spoiled food for lunch, it spelled terrible, and she still wanted to eat it.” What is the most likely physiological reason that the patient not realizes that the food is spoiled?

a.
She has xerostomia.
b.
She has a diminished sense of smell.
c.
She has a diminished sense of taste.
d.
She has a limited vision.

ANS: B

Olfactory changes begin around age 50 and include a loss of cells in the olfactory bulb of the brain and a decrease in the number of sensory cells in the nasal lining. Reduced sensitivity to odors is common. A small decrease in the number of taste cells occurs with aging, beginning around age 60. Reduced sour, salty, and bitter taste discrimination is common. The ability to detect sweet tastes seems to remain intact. Xerostomia is the decrease in salivary production that leads to thicker mucus and a dry mouth. This interferes with the ability to eat and leads to appetite and nutritional problems.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1113 | 1114 | 1124

OBJ:Discuss common sensory changes that occur with aging.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

4.The patient has a methicillin-resistant Staphylococcus aureus (MRSA) infection in an abdominal surgical wound. The patient is in a private room, is receiving vancomycin (Vancocin) for the MRSA, and pain is well controlled with a morphine sulfate patient-controlled analgesia (PCA) pump, and is receiving docusate sodium (Colace) to prevent constipation. During the nurse’s rounds, the patient begins complaining of ringing in the ears. Which is the most likely cause for the patient’s tinnitus?

a.
Surgical anesthesia
b.
Morphine sulfate
c.
Vancomycin
d.
Docusate sodium

ANS: C

Ototoxic medications, such as analgesics, antibiotics (such as vancomycin and aminoglycosides), or diuretics, affect hearing acuity, balance, or both, with the most common symptom being tinnitus (ringing in the ears). Surgical anesthesia, morphine, and docusate sodium do not have the side effect of ototoxicity or tinnitus.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1114 OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

5.An elderly patient with diabetes is seeing the health care provider for complaints of visual changes. The patient explains to the nurse that visual changes include distortion that makes the edges of objects appear wavy. The nurse knows that this is an early sign of which of the following?

a.
Cataracts
b.
Glaucoma
c.
Diabetic retinopathy
d.
Age-related macular degeneration

ANS: D

Age-related macular degeneration occurs when the macula (specialized portion of the retina responsible for central vision) degenerates as a result of aging and loses its ability to function efficiently. An early sign includes distortion that causes edges or lines to appear wavy. In later stages, patients may see dark or empty spaces that block the center of vision. Cataract is clouding of the lens in the eye that affects vision. Interferes with passage of light through the lens and reduces the light that reaches the retina. Cataracts usually develop gradually and often result in cloudy or blurry vision, glare, double vision, and poor night vision. Glaucoma is a slowly progressive increase in intraocular pressure that causes progressive pressure against the optic nerve. At first, vision stays normal, and there is no pain. If left untreated, there may be a loss of peripheral (side vision). Diabetic retinopathy are pathological changes of the blood vessels of the retina secondary to increased pressure resulting in hemorrhage, macular edema, and reduced vision or vision loss.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1114 OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

6.A nursing student is assisting with ambulation of a blind patient. The patient has hemiplegia of the right side. The best position for the student nurse to assume when ambulating is by standing on the patient’s _____ side and walking a half step _____ the patient.

a.
left; ahead
b.
right; ahead
c.
left; behind
d.
right; behind

ANS: A

You will need to assist patients with acute visual impairments with walking. Stand on the patient’s dominant, stronger, or uninjured side. The patient grasps your elbow or upper arm. You then walk one half step ahead and slightly to the patient’s side. The patient’s shoulder is directly behind your shoulder. Relax and walk at a comfortable pace.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1125

OBJ: Discuss ways to maintain a safe environment for patients with sensory alterations.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

7.A 16-year-old mother and her newborn come into the clinic for a routine checkup. The mother is concerned that her baby could be deaf because her uncle lost his hearing at a young age. The nurse hits a buzzer and the baby turns toward the sound. The nurse assures the mother that the baby can hear because the baby:

a.
was discharged from the hospital without any known problems.
b.
is producing ear wax.
c.
responds to loud noises.
d.
is too long young to determine any type of hearing loss.

ANS: C

Neonates without hearing impairments respond to loud noises. Atrophy of the cerumen glands, seen mainly in older adults, cause thicker and dryer wax, which is more difficult to remove and may completely obstruct the auditory canal. Hearing loss can be determined at any age with additional testing by an EENT specialist.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1113 OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

8.The spouse of a homebound elderly patient voices a concern to the visiting nurse, “I’m having a hard time getting the patient to eat a balanced diet. All the patient wants to eat are sweets.” What is the best explanation the nurse can give to the spouse?

a.
“Maybe she has a ‘sweet tooth.’”
b.
“Older adults seem to be able to taste sweet foods best.”
c.
“I wouldn’t worry about it as long as she is eating something.”
d.
“She is probably getting all the nutrients that she needs.”

ANS: B

A small decrease in the number of taste cells occurs with aging, beginning around age 60. Reduced sour, salty, and bitter taste discrimination is common. The ability to detect sweet tastes seems to remain intact. Promote sense of taste through good oral hygiene, serving well-seasoned and differently textured foods, chewing food thoroughly, and avoiding blending or mixing foods. Enhance the sense of smell by removing unpleasant odors from the environment and introducing pleasant smells such as mild room deodorizers or fragrant flowers.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1113 | 1123 OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

9.The school nurse is performing periodic screening on preschool children. She is aware that the most common visual problem in childhood is which of the following?

a.
Refractive errors
b.
Strabismus
c.
Congenital blindness
d.
Color blindness

ANS: A

Periodic screening of all children, especially newborns through preschoolers, should be performed for congenital blindness and visual impairment caused by refractive errors and strabismus. The most common visual problem during childhood is a refractive error such as nearsightedness. The school nurse is usually responsible for vision testing of school-age and adolescent children. Your role as a nurse is one of detection, education, and referral. Parents need to know the signs of visual impairment such as failure to react to light and reduced eye contact from the infant. Instruct parents to report signs of visual impairment to their health care provider.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:1122

OBJ: Discuss ways to maintain a safe environment for patients with sensory alterations.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

10.A nurse is caring for a patient who signs and lip reads. When communicating, the mostappropriate nursing action is to do which of the following?

a.
Rely on family members to interpret.
b.
Speak louder and more distinctly than normal.
c.
Sit facing the patient when speaking.
d.
Repeat the entire conversation if it is not understood the first time.

ANS: C

Nurses can use a variety of communication techniques, including reading notes and writing notes, as well as reading lips and signing. When communicating, nurses should speak slowly and articulate clearly. When you are not understood, rephrase rather than repeating the entire conversation. Some patients with hearing impairments are able to speak normally. To more clearly hear what a person communicates, family and friends need to learn to move away from background noise, rephrase rather than repeat sentences, be positive, and have patience. On the other hand, some deaf patients have serious speech alterations. Patients who are deaf use sign language, read lips, write with pad and pencil, or learn to use a computer for communication

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1124

OBJ:Describe nursing interventions with rationale that promote effective communication with patients who have sensory alterations.

TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

11.An older adult patient has been admitted to a busy medical unit. To control environmental stimuli a nurse should do which of the following?

a.
Leave the hospital room lights on at all times.
b.
Turn off bedside equipment not in use.
c.
Leave the window curtains closed at all times.
d.
Leave the door open so the patient can hear the staff and feel secure.

ANS: B

Try to control extraneous noise in and around a patient’s room, such as television volume and visitors. Turn off bedside equipment not in use. Close a patient’s room door if necessary. Hospital staff members need to control loud laughter or conversation at the nurses’ station. In addition to controlling excess stimuli, try to introduce meaningful stimulation that makes the environment pleasing and comfortable. Open drapes and close door if indicated. Control extraneous noise in and around room such as television volume and visitors. Turn off bedside equipment not in use.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1125

OBJ:Describe conditions in the health care agency or patient’s home that you will adjust to promote meaningful sensory stimulation.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

12.The student nurse is assisting an elderly patient to get ready for bed. The patient states, “Please make sure you clean my hearing aids.” The student nurse knows it is important to keep in mind which of the following when cleaning a hearing aid?

a.
Keep the battery in the machine when turned off.
b.
Store the hearing aid on the overnight table for easy access at night.
c.
Clean the hearing aid with hot water.
d.
Use a soft dry cloth to wipe the hearing aid.

ANS: D

Care for hearing aids include:

• Make sure your fingers are dry and clean before handling hearing aids.

• Insert and remove the hearing aid over a soft surface.

• Place the battery in the hearing aid when it is turned off.

• Remove the hearing aid battery when not in use and store it in a marked container in a safe place.

• Protect hearing aids from water and excessive heat or cold.

• Use a soft dry cloth to wipe hearing aids and a soft brush to clean difficult to reach areas.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF: 1123 OBJ: Discuss common sensory changes that occur with aging.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

13.A school nurse performs a routine screening on a newly transferred school-age child. This nurse is especially interested in discovering the child’s medical history regarding middle ear infections. The nurse knows that chronic ear infections are a major contributing factor to which of the following?

a.
Respiratory diseases
b.
Strep throat
c.
High fevers
d.
Hearing impairment

ANS: D

Hearing impairment is common in the United States. At-risk children include those with a family history of childhood hearing impairment, perinatal infection (rubella, herpes, or cytomegalovirus), low birth weight, chronic ear infections, and Down syndrome. Children need periodic auditory testing. Advise pregnant women of the importance of early prenatal care, avoidance of ototoxic drugs, and testing for syphilis and rubella. Strep throat, high fevers, and respiratory diseases are potential contributing factors for chronic ear infections.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1122 OBJ: Discuss common causes and effects of sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Physiological Integrity

14.An older adult patient residing at an adult assisted living facility complains of hearing and visual disturbances. A nurse must be alert to the effects of sensory deprivation that are associated with which of the following?

a.
Stable affect
b.
Altered perception
c.
Improved task completion
d.
Decreased need for social interaction

ANS: B

Sensory deprivation sometimes produces cognitive changes such as the inability to solve problems, poor task performance, and disorientation. It also can cause affective changes (e.g., boredom, restlessness, increased anxiety, emotional lability) and/or perceptual changes (e.g., reduced attention span, disorganized visual and motor coordination, confusion of sleeping and waking states). Patients may withdraw from social situations because of their inability to handle stimuli.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1112 OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

15.A patient with poor vision is ready to be discharged. The nurse is educating the patient and family regarding ways to improve vision. The nurse teaches the patient and family to avoid reading materials with shiny surfaces. The rationale for this intervention is which of the following?

a.
Glare causes headaches.
b.
Glare will reduce visual acuity.
c.
Shiny surfaces reflect damaging rays.
d.
Too much light is damaging to the eyes.

ANS: B

When a patient ages, the pupil loses the ability to adjust to light. Therefore reducing the amount of bright light in the patient’s environment will assist vision. Reduce glare by eliminating waxed floors and shiny surfaces exposed to bright sunlight, tint glass, install sheer curtains over windows, and use soft and diffused lighting.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1123

OBJ: Develop a nursing care plan for patients with visual, auditory, tactile, gustatory, and olfactory alterations. TOP: Nursing Process: Implementation

MSC:Client Needs: Psychosocial Integrity

16.A home care nurse visits a new patient. The family asks how the home can be made safer. The nurse’s best advice includes which of the following?

a.
Using throw rugs to prevent tripping
b.
Installing extra incandescent lighting
c.
Painting the floor black and white to add perception
d.
Installing handrails painted the same color as the walls

ANS: B

Good lighting at front and back entrances and light switches at the top and bottom of stairwells and long hallways add an additional safety element. Throw rugs, footstools, and electrical cords present tripping hazards. Handrails painted the same color as the walls may pose a problem for the visually impaired. Using color contrasts such as tape, paint, or nail enamel can highlight items.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1119 | 1120

OBJ:Describe conditions in the health care agency or patient’s home that you will adjust to promote meaningful sensory stimulation.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

17.A patient has been hospitalized for 5 days and has had no visitors. The nurse observes the patient to be bored, restless, and anxious. The nurse identifies this behavior as which of the following?

a.
Sensory deficits
b.
Sensory overload
c.
Sensory deprivation
d.
Changes in attitudes

ANS: C

Sensory deprivation occurs when inadequate quality or quantity of stimuli impairs a patient’s perception. It can cause affective changes (e.g., boredom, restlessness, increased anxiety, emotional lability) and/or perceptual changes (e.g., reduced attention span, disorganized visual and motor coordination, confusion of sleeping and waking states). Sensory deficits such as low vision and blindness are very common forms of disability. When a person receives multiple sensory stimuli, the brain has difficulty distinguishing the stimuli, leading to sensory overload. A person with sensory overload no longer perceives the environment in a way that makes sense. Sensory deprivation can be caused from living in a nonstimulating environment. Ask the patient how to improve the quality of stimulation in the environment.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:1112

OBJ: Differentiate the processes of reception, perception, and reaction to sensory stimuli.

TOP: Nursing Process: Evaluation MSC: Client Needs: Psychosocial Integrity

MULTIPLE RESPONSE

1.A nursing student is concerned with sensory deprivation among the patients in the nursing home during the clinical rotation. Which of the following could be caused by sensory deprivation? (Select all that apply.)

a.
Confusion
b.
Anxiety
c.
Disorientation
d.
Panic
e.
Aggressiveness

ANS: A, B, C

Sensory deprivation occurs when inadequate quality or quantity of stimuli impairs perception. These effects sometimes produce cognitive changes, such as the inability to solve problems, poor task performance, and disorientation. Affective changes, which include boredom, restlessness, increased anxiety, or emotional ability, can occur. Symptoms of sensory overload include panic, confusion, and aggressiveness.

PTS:1DIF:Cognitive Level: Applying (Application)

REF: 1112 OBJ: Describe behaviors indicating sensory alterations.

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

2.A home care nurse is conducting a home assessment. The nurse is looking for the presence of sensory alterations. Factors to assess include if any changes have occurred in which of the following? (Select all that apply.)

a.
Activities of ADLs
b.
Health promotion
c.
Has person had visitors
d.
Is person wearing hearing aids and glasses
e.
Ability to follow a conversation

ANS: A, B, C, D, E

When assessing for sensory alterations, home care nurses need to assess sensory status, self-care management, and health promotion activities, as well as lifestyle and socialization.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:1117

OBJ:Identify factors to assess in determining a patient’s sensory status.

TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

3.A middle-age patient was admitted to the trauma intensive care unit after a motor vehicle accident. The nurse notes that the patient becomes increasingly agitated when visitors stay for an extended period or after nursing interventions. The nurse identifies this as sensory overload. Which of the following would most likely help the patient? (Select all that apply.)

a.
Reducing the number of visitors to her room
b.
Performing dressing changes with the bath
c.
Providing a dedicated period of rest time each afternoon
d.
Requesting that health care providers do rounds when the family is available
e.
Coordination with other departments for tests and examinations

ANS: A, B, C, E

Reduce sensory overload by organizing the patient’s care to control for excessive stimuli. Combining activities such as dressing changes, bathing, and vital sign assessment in one visit prevents the patient from becoming overly fatigued. Coordination with other departments will reduce the time needed for tests and examinations. The patient needs time for rest and quiet. Although it is important for health care professionals to communicate to family members, it will not likely reduce sensory overload for the patient.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF: 1116 | 1125 OBJ: Describe behaviors indicating sensory alterations.

TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment