1.) The plan of care for a client exhibiting signs of 12.

) A cycling accident has resulted in a

sensory deprivation includes incorporating head injury to a male client and he has been
tactile stimulation. which nursing intervention admitted to the intensive care unit for the
will provide tactile stimulation? PROVIDING A treatment of increased intracranial pressure.
BACKRUB WITH MORNING AND EVENING Consequently, he has been placed in a private
CARE room with low light and his care has been
2.) Which of the following situations organized to minimize disturbances. What
demonstrates sensory adaptation? A PATIENT nursing diagnosis is the client at risk for?
HAS LEARNED TO SLEEP THROUGH THE SENSORY DEPRIVATION
FREQUENT BEEPING OF HER INTRAVENOUS 13.) A resident of a long-term care facility
PUMP has moderate hearing loss. When
3.) A special needs child has been placed in a communicating with the resident, what should
classroom with other special needs children. the nurse do? MINIMIZE BACKGROUND
The classroom is noisy with a high level of NOISES AND ENSURE THE LIGHTING IS
activity, and the child appears to have ADEQUATE TO SEE THE NURSE’S FACE
difficulty concentrating on his work. What is 14.) A client brought to the emergency
the child likely experiencing? SENSORY room in unconscious and cannot be aroused.
OVERLOAD The client is breathing and has a heartbeat.
4.) A hospitalized client who refuses to eat What state of awareness is the client
because she fears that kitchen personnel are exhibiting? COMA
poisoning her food is experiencing what? 15.) A client informs the nurse that she is
DELUSIONS not able to recall her phone number or
5.) During the nurse’s morning assessment of a address, and this is disconcerting. The nurse
client with a diagnosis of dementia, the client recognizes that the inability to recall
states that the year is 1949 and she believes information is indicative of which
she is in a hotel. How should the nurse best sensory/perception problem? IMPAIRED
respond to this client’s disorientation? MEMORY
REORIENT THE PATIENT TO PLACE AND TIME 16.) You enter Mrs. Angelo’s room in the
6.) Which of the following clients is most likely surgical unit for the first time. She is a 60 year
susceptible to the effects of disturbed sensory old woman schedule for gallbladder surgery
perception? A PATIENT RECEIVING CARE IN today. You plan to complete some pre op
THE INTENSIVE CARE UNIT (ICU) FOR THE teaching. You know, but don’t get any answer,
TREATMENT OF SEPTIC SHOCK so you enter. She watches you intently, looks
7.) A child 4 years of age has a mother who is worried, but is nodding and smiling. You ask if
employed and works from home. To she has any questions about her surgery, and
accomplish her daily work, she allows the she answers: “Yes dear!” smiling, but does not
child to watch television for six to eight hours ask a question. What is going on? HEARING
a day. Based upon this information, what LOSS
nursing diagnosis would be applicable to this 17.) A nurse asks a patient to close her
family? IMPAIRED PARENTING ASSOCIATED eyes, state when she feels something and
WITH FAILURE TO PROVIDE STIMULI FOR describe the feeling. The nurse then brushes
GROWTH the patient’s skin with a cotton ball, and
8.) A client returning from the operating room is touches the patient’s skin with both sides of a
unconscious. What guidelines should the safety pin. Which sense is the nurse
nurse consider when communicating with this assessing? TACTILE
client? TALK TO THE PATIENT IN A NORMAL 18.) A nurse observes that a patient who
TONE OF VOICE has cataracts is sitting closer to the television
9.) A neonatal intensive care nurse is caring for an than usual. The nurse would interpret that the
infant born prematurely. How will the nurse etiologic basis of this sensory problem is an
manage the infant’s environment to best alteration in: SENSORY RECEPTION
support his sensory needs? LIMIT LIGHTING, 19.) A patient is in the late stages of AIDS,
VISUAL, AND VESTIBULAR STIMULATION which is affecting his brain as well as other
10.) An older adult client who is in a long- major organ system. The patient confides to
term care facility tells the nurse, “I’m not the nurse that he feels terribly alone because
eating that, it’s poisoned.” The nurse interprets most of his friends are afraid to visit. The nurse
this as which manifestation of altered sensory determines that the least likely underlying
perception? DELUSION etiology for his sensory problems would be:
11.) A client has expressed great relief at EMOTIONAL RESPONSES
the improvement in her hearing after irrigation 20.) Which patient would a nurse assess as
of her ear canal yielded a large amount of being at greater risk for sensory deprivation?
impacted cerumen (wax). This client was AN OLDER MAN CONFINED TO BED AT
experiencing a sensory alteration related to HOME AFTER A STROKE
which of the following? SENSORY 21.) A nurse is diagnosing an 11-year-old 6th
RECEPTION grade student following a physical
 assessment. The nurse notes that the Which strategy should the nurse use to deal
student’s grades have dropped, she has with the client’s distorted perceptions and
difficulty completing her work on time, and feelings? PROVIDE OBEJCTIVE DATA AND
she frequently rubs her eyes and squints. Her FEEDBACK REGARDING THE CLIENT’S
visual acuity on a Snellen’s eye chart is WEIGHT AND ATTRACTIVENESS
160/20. Which nursing diagnosis would be 29.) A male client is color blind. The nurse
most appropriate? INEFFECTIVE ROLE understands that this client has a problem
PERFORMACE (STUDENT) RELATED TO with: CONES
VISUAL IMPAIRMENT 30.) If a male client experienced a
22.) A nurse is caring for a male patient with cerebrovascular accident (CVA) that damaged
a severe hearing deficit who is able to read lips the optic nerve, the nurse would anticipate
and use sign language. Which nursing that the client has problems with: A BODY
intervention would be best to prevent sensory TEMPERATURE CONTROL
alterations for this patient? PROVIDE DAILY 31.) Sensory Stimulation can only be
OPPURTUNITY FOR HIM TO PARTICIPATE IN performed among clients with mental
A SOCIAL HOUR WITH SIX TO EIGHT PEOPLE disorders. FALSE
23.) In a group home in which most 32.) Mr. X mistakes the voice of Nurse
patients have slight to moderate visual or Alfred as “Manong Merkat,” his imaginary fried
hearing impairment and some are periodically who talks to him when he is alone. As a nurse,
confused, what would be a nurse’s first priority you understand that this manifestation is
in caring for sensory concerns? MAINTAINING called hallucination. TRUE
SAFETY AND PREVENTING SENSORY 33.) In testing the senses, it is best to use
DETORIORATION two contrasting stimuli to allow for
24.) A nurse formulated the following differentiation. TRUE
nursing diagnosis for an 8-month-old infant. 34.) Lagda is a set of rules that a nurse or
Disturbed Sensory Perception: Sensory therapist should state before every start of the
Deprivation related to inadequate parenting. therapy. TRUE
Since that diagnosis was made, both parents 35.) While watching television, a news
have attended parenting classes. However, anchor reported about a fire that razed a whole
both parents work while the infant stays with village. Mr. X hurriedly went to his room and
her 86-year-old grandmother, who has cried believing that the incident occurred
reduced vision. The parents provide because he did not follow the rules and
appropriate stimulation in the evening. At an guidelines in the ward. As a nurse, you
evaluation conference at the age of 11 months understand that this is a sign of delusion.
the infant lies on the floor sucking her thumb TRUE
and rocking her body. Her facial expression is 36.) Sensory Stimulation is
dull, and she vocalizes only in a low monotone contraindicated for clients with dementia.
(“uh-h-h”). which statement accurately FALSE
reflects evaluation about the child’s sensory 37.) In Sensory Stimulation, the client’s
deprivation? THE INFANT’S SENSORY sensual activity is being tested. This includes
DEPRIVATION IS STILL SEVERE the ability of the client to feel pain elicited by
25.) An older female patient has a severe the nurse. FALSE
visual deficit related to glaucoma. Which 38.) Sensory Stimulation is
nursing action would be appropriate when contraindicated for clients with hearing or
providing care for this patient? INDICATE TO visual impairment and adults with
THE PATIENT WHEN THE CONVERSATION developmental abilities. FALSE
HAS ENDED AND WHEN THE NURSE IS 39.) Before the start of the therapy, instruct
LEAVING THE ROOM clients to attend to their needs first to avoid
26.) Which of the following descriptions of distractions during the session. TRUE
patient experience and behavior can be 40.) In blindfolding the clients during
assessed as an illusion? A patient: LOOKS AT sensory stimulation, instruct the student
THE SHADOW ON A WALL AND TELLS THE nurses to use both of their hands to cover the
NURSE SHE SEES FRIGHTENING FACES ON client’s eyes. FALSE
THE WALL
27.) A client admitted to the mental health
unit is experiencing disturbed thought
processes and believed that the food is being
poisoned. Which communication technique
would a nurse plan to use to encourage the
client to eat? USING OPEN-ENDED
QUESTIONS AND SILENCE
28.) A 24-year-old client with anorexia
nervosa tells the nurse, “When I look in the
mirror, I hate what I see. I look so fat and ugly.”