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Sensory alterations - Pottery and Perry Test Bank
Fundamentals of Nursing (Long Island University)
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Potter & Perry: Fundamentals of Nursing, 7th Edition
Test Bank
Chapter 49: Sensory Alterations
MULTIPLE CHOICE
1. During a community screening, the nurse informs a 50-year-old African American client
about the frequency of eye examinations. It is recommended that individuals in this agegroup have eye examinations:
1. Every 3 to 4 months
2. Every 6 months
3. Every 1 to 2 years
4. Every 4 years
ANS: 3
Clients between the ages of 40 and 64 should have an eye examination every 1 to 2 years
if there is a family history of glaucoma or if the client is of African ancestry.
DIF: A
REF: 1355
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
2. With advancing age, which of the following normal physiological changes in sensory
function occurs?
1. Decreased sensitivity to glare
2. Increased number of taste buds
3. Difficulty discriminating vowel sounds
4. Decreased sensitivity to pain
ANS: 4
Older adults experience tactile changes, including declining sensitivity to pain, pressure,
and temperature. Older adults have an increased sensitivity to glare. Older adults have a
decreased number of taste buds. Older adults have difficulty discriminating the
consonants (z, t, f, g) and high-frequency sounds (s, sh, ph, k).
DIF: A
REF: 1346
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
3. The nurse teaches a client that prolonged use of the antibiotic streptomycin may result in:
1. Damage to the auditory nerve
2. Alteration in perception
3. Optic irritation
4. Loss of taste
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Test Bank
ANS: 1
Some antibiotics, such as streptomycin, gentamicin, and tobramycin, are ototoxic and can
permanently damage the auditory nerve. Narcotic analgesics, sedatives, and
antidepressant medications can alter the perception of stimuli. Chloramphenicol can
irritate the optic nerve.
DIF: A
REF: 1351
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
4. Which of the following occupations poses the least risk for sensory alterations?
1. Waiter
2. Welder
3. Computer programmer
4. Construction worker
ANS: 1
The waiter is at least risk for sensory alterations. A welder is at risk for visual alterations.
A computer programmer is at risk for peripheral nerve injury. A construction worker is at
risk for hearing alterations.
DIF: A
REF: 1356
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
5. The nurse is working with a client with a moderate hearing impairment. To promote
communication with this client, the nurse should:
1. Use a louder tone of voice than normal
2. Use visual aids such as the hands and eyes when speaking
3. Approach a client quietly from behind before speaking
4. Select a public area to have a conversation
ANS: 2
To promote communication with the client who has a hearing impairment, the nurse
should use visible expressions, such as speaking with the hands, face, or eyes. A normal
tone of voice and inflections of speech should be used when communicating with a client
with a hearing impairment. The nurse should get the client’s attention and not startle the
client when entering a room. The nurse should not approach a client from behind. It is
best to select a quiet environment without background noise to facilitate communication
when a client is hearing impaired.
DIF: A
REF: 1358
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
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Test Bank
49-3
6. The client has hyperesthesia apparently associated with a neurological trauma. Which of
the following is an appropriate nursing intervention in regard to the client’s sense of
touch?
1. Reminding the client of the need to have frequent tactile contact
2. Keeping the client loosely covered with sheets and blankets
3. Allowing the client to lie motionless
4. Using touch as a form of therapy
ANS: 2
If a client is overly sensitive to tactile stimuli (hyperesthesia), the nurse must minimize
irritating stimuli. Keeping bed linens loose to minimize direct contact with the client and
protecting the skin from exposure to irritants are helpful measures. Frequent tactile
contact is not an appropriate intervention for the client with hyperesthesia. Allowing the
client to lie motionless is not an appropriate intervention for the client with hyperesthesia.
Using touch as a form of therapy would not be an appropriate nursing intervention for the
client with hyperesthesia.
DIF: A
REF: 1357
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
7. The client has experienced a cerebral vascular accident (stroke) with resultant expressive
aphasia. The nurse promotes communication with this client by:
1. Speaking very loudly and slowly
2. Speaking to the client on the unaffected side
3. Using a picture chart for the client’s responses
4. Using hand gestures to convey information to the client
ANS: 3
For the client with aphasia, the nurse can communicate using a picture chart or
communication board for the client’s responses. The nurse should not speak loudly and
slowly to the client with expressive aphasia. The client is able to understand; this may
seem patronizing to the client. The nurse should not speak to the client on the unaffected
side, as this will not improve communication. Using hand gestures to convey information
to the client may be helpful for the client with receptive aphasia, not expressive aphasia.
DIF: A
REF: 1350
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
8. The client was working in the kitchen and was splashed in the face with a caustic
cleaning agent. His eyes were affected, and he was brought to the hospital for treatment.
After cleansing and evaluation, his eyes were bandaged. When assisting this client, who
has temporary visual loss, to eat the nurse should:
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Test Bank
1.
2.
3.
4.
Feed the client the entire meal
Allow the client to experiment with foods
Orient the client to the location of the foods on the plate
Assign ancillary personnel to feed the client
ANS: 3
A meal tray can be set up as a clock. The visually impaired client can easily become
oriented to the items after the nurse or family member explains each item’s location. This
enables the client to perform self-care (feeding), which is essential for self-esteem. The
client should be allowed to feed himself to maintain self-esteem. Allowing the client to
experiment with foods is not assisting the client in performing self-care. The client should
be allowed to feed himself to maintain self-esteem.
DIF: A
REF: 1361
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
9. The nurse completes a safety assessment during a home visit to an older adult client. Of
the following observations made by the nurse, the one that is of greatest concern for this
client who has evidence of sensory impairment is:
1. Low-pile carpeting throughout the home
2. A handrail on the stairs that extends the full length
3. Higher wattage incandescent lighting in all the rooms
4. The gray/black settings on the stove handles
ANS: 4
Sometimes settings on electrical appliances and equipment are only highlighted in black
and white or shades of gray. Color contrasts help to distinguish settings. The greatest
concern for safety for the client with sensory impairment is the gray/black setting on the
stove handles. Low-pile carpeting helps to prevent falls. A handrail on the stairs that
extends the full length is beneficial for preventing falls. Higher wattage incandescent
lighting helps prevent glare and is an appropriate adaptation for visual loss.
DIF: C
REF: 1356
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
10. A client is legally blind in both eyes. Which of the following is the most appropriate
statement for the nurse to make to the client regarding providing the client with
assistance?
1. “I will walk in front of you, and you can hold onto my belt.”
2. “I know that you must need me to be your sighted guide to get around in this
facility.”
3. “I will warn you of upcoming curbs or stairs.”
4. “I will get you a wheelchair so that I can move you around safely.”
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Test Bank
ANS: 3
To assist the client who is legally blind, the nurse should warn the client when
approaching doorways or narrow spaces, including upcoming curbs or stairs. To assist the
client who is legally blind, the nurse should walk one-half step ahead and slightly to the
side of the visually impaired person. The client can place his or her hand on the nurse’s
forearm. Often sensorially impaired clients can help themselves, and it is essential that
they do so for self-esteem. The client who is able should be encouraged to ambulate.
DIF: A
REF: 1360
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
11. A 79-year-old client drives his car in the local areas near his home. The most appropriate
driving tip for the nurse to give this client is:
1. “Go very, very slow so you will have some chance of reacting”
2. “Take your time on long road trips when you are by yourself”
3. “Remember to keep your car maintained with regular checkups”
4. “To avoid sun glare, you should drive at night”
ANS: 3
A safety tip the nurse can share with this client is to keep the car in good working
condition. The nurse should advise the client to go slow, but not too slow, for safety. The
nurse can offer the driving tip to drive in familiar areas, not on long road trips by himself
or herself. The client should be advised to avoid driving at dusk or at night.
DIF: A
REF: 1356
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
12. An older adult client in a nursing home has visual and hearing losses. The nurse is alert to
which of the following signs that represents the effects of sensory deprivation?
1. Diminished anxiety
2. Improved task completion
3. Altered spatial perception
4. Decreased need for physical stimulation
ANS: 3
Altered spatial perception, increased anxiety, poor task performance, and an increased
need for physical stimulation are all signs of sensory deprivation.
DIF: A
REF: 1345
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
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Test Bank
13. During a home safety assessment, the nurse identifies that there are a number of hazards
present. Of the following hazards that are noted by the nurse, which one represents the
greatest risk for this client with diabetic peripheral neuropathy?
1. Improper water heater settings
2. Absence of smoke detectors
3. Cluttered walkways
4. Lack of bathroom grab bars
ANS: 1
Clients with impaired tactile sensation, as the client with diabetic neuropathy, should be
cautioned to have the setting on the water heater no higher than 120° F. The greatest risk
for the client with diabetic peripheral neuropathy is an improper water heater setting,
because the client would not be able to feel a setting that is too hot and could therefore
experience injury. An absence of smoke detectors is not the greatest risk for the client
with diabetic peripheral neuropathy. It would be of greater risk for the client who has an
olfactory impairment. Although a lack of bathroom grab bars may place a client at risk
for falls, it is not the greatest risk for the client with diabetic peripheral neuropathy.
DIF: C
REF: 1358
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
14. The nurse in the pediatric clinic is checking the basic visual acuity of a 4-year-old child.
The nurse should have the child:
1. Use the standard Snellen chart
2. Read a few lines from a children’s book
3. Follow the peripheral movement of an object
4. Identify crayon colors
ANS: 4
To assess basic visual acuity, the nurse should ask the client to identify crayon colors. The
Snellen chart may be used for the adult client but would be less appropriate for the 4year-old child.
DIF: A
REF: 1350
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
15. For a client with receptive aphasia, which one of the following nursing interventions is
the most effective?
1. Providing the client with a letter chart to use to answer complex questions
2. Using a system of simple gestures and repeated behaviors to communicate
3. Offering the client a notepad to write questions and concerns
4. Obtaining a referral for a speech therapist
ANS: 2
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Test Bank
If the client has problems with comprehension, as in receptive aphasia, the nurse should
use simple short questions, facial gestures, and repeated behaviors to communicate.
Providing a client with a letter chart would be more appropriate for the client with
expressive aphasia. Questions should be simple, not complex, to aid comprehension. A
notepad would be appropriate for the client with expressive aphasia, not receptive
aphasia. Clients with expressive aphasia often require a speech therapist, not a client with
receptive aphasia.
DIF: C
REF: 1350
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
16. The nurse recommends follow-up auditory testing for a child who was exposed in utero
to:
1. Excessive oxygen
2. Diabetes
3. Respiratory tract infection
4. Rubella
ANS: 4
Children at risk for hearing impairment include those who were exposed to rubella in
utero. Children at risk for visual impairment include those who received excessive
oxygen as a newborn.
DIF: A
REF: 1356
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
17. The family of an older client asks the nurse how the stairways and hallways in the home
may be enhanced to promote safety. In addition to extra lighting, the nurse recommends
the use of paint and decorations that are:
1. Red and yellow
2. Black and white
3. Brown and green
4. Blue and purple
ANS: 1
Brighter colors such as red, orange, and yellow are easier for the older adult to see. Black
and white colors are not the best recommendation for promoting safety in the older adult.
Perception of the colors blue, violet, and green usually declines with age.
DIF: A
REF: 1356
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
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49-8
Test Bank
18. The nurse is working with older adult clients in an extended care facility. To enhance the
clients’ gustatory sense, the nurse should:
1. Mix foods together
2. Assist with oral hygiene
3. Provide foods of similar texture and consistency
4. Make sure foods are extremely spicy
ANS: 2
Good oral hygiene keeps the taste buds well hydrated and will enhance the client’s
gustatory sense. Taste perception is heightened if foods are eaten separately, are different
textured, and are well seasoned.
DIF: A
REF: 1350
OBJ: Comprehension
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
19. A home safety measure specific for a client with diminished olfaction is the use of:
1. Smoke detectors on all levels
2. Extra lighting in hallways
3. Amplified telephone receivers
4. Mild water heater temperatures
ANS: 1
A reduced sensitivity to odors means that the client may be unable to smell a smoldering
fire. The client should use smoke detectors as a safety measure. A home safety measure
specific for a client with diminished vision is the use of extra lighting in hallways. A
home safety measure specific for a client with diminished hearing is the use of amplified
telephone receivers. A home safety measure specific for a client with reduced tactile
sensation is having mild water heater temperatures.
DIF: A
REF: 1358
OBJ: Comprehension
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
20. The nurse has completed the admission assessment for a client admitted to the hospital’s
subacute care unit. Of the following nursing diagnoses identified by the nurse, the one
that takes the highest priority is:
1. Social isolation
2. Risk for injury
3. Risk-prone health behavior
4. Impaired verbal communication
ANS: 2
Safety is always a top priority.
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Test Bank
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DIF: C
REF: 1352
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
21. While participating in a community auditory screening, the nurse is alert to the
population that has the greatest prevalence of problems. The nurse is aware that hearing
impairment is more common for:
1. Whites
2. Asian Americans
3. African Americans
4. Native Americans
ANS: 1
Whites have more hearing impairment problems than African Americans and Asian
Americans. African Americans are at greater risk for glaucoma, not for hearing
impairment. Otitis media is more prevalent among Native Americans than among whites.
DIF: A
REF: 1346
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
22. The nurse is visiting the day care center for routine assessment of the children. After
spending time with the children in one of the playrooms, the nurse suspects that a child
has a visual deficit as a result of observing:
1. Poor balance and gait
2. An increase in weight
3. Sitting and rocking back and forth
4. A failure to respond when touched
ANS: 3
Behaviors of children indicating a possible visual deficit include self-stimulation such as
eye rubbing, body rocking, sniffing or smelling, and arm twirling. Poor balance and gait
may indicate an impairment of position sense in the adult. A weight change may indicate
a deficit in taste in the adult. Failure to respond to touch may indicate a touch deficit in
the adult.
DIF: A
REF: 1350
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
23. A client has been in the intensive care unit for 4 days and has begun to show signs of
restlessness and anxiety even though the client has been reassured that his or her
condition is improving and discharge to the unit will be occurring soon. The cause of the
client’s emotional state is a result of:
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Test Bank
1.
2.
3.
4.
Fear of death
Social isolation
Sensory overload
Anxiety disorder
ANS: 3
The acutely ill client easily falls victim to sensory overload. The client in constant pain or
who undergoes frequent monitoring of vital signs or who has irritation from drainage
tubes is at risk.
DIF: A
REF: 1345
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
24. A client has been in the intensive care unit for 4 days and has begun to show signs of
restlessness and anxiety, and the nurse believes the client is experiencing sensory
overload. Which of the following interventions will be most therapeutic in assisting the
client?
1. Limiting interaction with the client to the safe minimum
2. Moving the client to a space furthest from the nursing station
3. Keeping the client’s lights dimmed and curtains partially drawn
4. Asking the client’s health care provider to consider early discharge to the unit
ANS: 3
Constant reorientation and control of excessive stimuli becomes an important part of the
client’s care. Although the remaining options may have value, they are not the most
therapeutic because external stimulation is the most likely cause of the problem.
DIF: C
REF: 1345
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
25. The wife of a 70-year-old client who is recuperating at home from hip replacement
surgery expresses a concern to the nurse that “He must be getting depressed. He just
doesn’t interact with people like he used to.” Which of the following is the nurse’s most
therapeutic response?
1. “Are there any other signs of depressions?”
2. “Does he usually enjoy interacting with visitors?”
3. “Do you think he may be having difficulty hearing what people are saying to him?”
4. “Well he could be. Do you want me to see if his health care provider will order an
antidepressant?”
ANS: 3
A concern with normal age-related sensory changes is that older adults with a deficit are
sometimes inappropriately diagnosed with dementia or depression. The remaining
options assume that depression may be the cause of his personality change.
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Test Bank
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DIF: C
REF: 1345
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
26. A 54-year-old client expresses concern about her weakening sense of smell to the nurse
during an admission interview. The nurse’s most therapeutic response is:
1. “I don’t think it is anything to worry about, but you could mention it to your health
care provider”
2. “That is really a fairly common complaint of people your age; I don’t think there is
anything to worry about”
3. “As long as you can smell things like smoke if there is a fire, I think it is something
you need to get used to”
4. “As long as you can smell things like smoke if there is a fire, I think it is something
you need to get used to”
ANS: 4
Gustatory and olfactory changes begin around age 50 and include a decrease in the
number of taste buds and a decrease in the number of sensory cells in the nasal lining.
Reduced taste discrimination and reduced sensitivity to odors are common. The
remaining options do not provide the most likely cause of the sensory deficit.
DIF: C
REF: 1345-1346
OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
27. The daughter of a client recently admitted to a skilled nursing facility shares with the
nurse that she is concerned about how disinterested her mother seems in everyone and
everything around her. The most therapeutic response by the nurse is:
1. “Bring something from home for her to display in her room”
2. “It is most likely just her way of adjusting to leaving her home”
3. “Many of the residents have this problem when they first come here”
4. “Just give her time to adjust; she’ll get more involved in a few days”
ANS: 1
Meaningful stimuli reduce the incidence of sensory deprivation. The presence or absence
of meaningful stimuli influences alertness and the ability to participate in care. The
remaining options simply attempt to explain away the behavior.
DIF: C
REF: 1346
OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
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Test Bank
28. The nurse is discussing vision and hearing health with a group of senior citizens. Which
of the following individuals should be given special encouragement to have regular eye
screenings for the presence of glaucoma?
1. An African American with hypertension
2. An Asian with osteoarthritis in the hands
3. A white with peripheral vascular disease
4. A Hispanic with type 2 diabetes
ANS: 1
Glaucoma is almost 3 times as common in African Americans as in white Americans. The
remaining options represent ethnic groups with eye-related risk factors but not
necessarily for glaucoma.
DIF: C
REF: 1346
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
29. Which of the following statements made by a client diagnosed with diabetes shows the
most informed understanding of the effect of the disease on optic health?
1. “The scariest part about having diabetes is the increased possibility of losing my
eyesight.”
2. “I have my eyes checked yearly to be aware of any retinopathy that may be
developing.”
3. “If I do a good job of keeping my blood sugars in line, I won’t run such a risk for
eye problems.”
4. “I try to keep my A1C below 7 so I can minimize the bad effects of hyperglycemia
on my eyes.”
ANS: 2
Hispanic Americans have an increased incidence of diabetic retinopathy. Although the
remaining options reflect a general understanding, they are not as specific nor do they
mention the specific self-care measures related to vision.
DIF: C
REF: 1346
OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
30. The nurse and a 69-year-old client are discussing the client’s report of “Not hearing as
well as I used to; I must be getting old.” Which of the following nursing responses is
most therapeutic regarding the client’s assumption of the cause of the diminished
hearing?
1. “What makes you think you don’t hear as well as you used to?”
2. “Well, hearing loss does seem to be more of a problem as we age.”
3. “You may be right, but I suggest you see an otolaryngologist just to be sure.”
4. “Do you turn the television up louder, or is it difficult to hear on the telephone?”
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Test Bank
ANS: 3
Be careful to not automatically assume that a client’s sensory problem is related to
advancing age. The suggestion to see a otolaryngologist is the most therapeutic because it
provides a means to rule out more serious conditions. The remaining options either
attempt to further identify the symptoms of the client’s problems or simply agree with the
theory of aging.
DIF: C
REF: 1345
OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
31. The nurse and a 62-year-old client are discussing the client’s sense of hearing. Which of
the following assessment questions is most likely to launch a conversation concerning the
client’s ability to hear effectively?
1. “Do you think you have a hearing problem?”
2. “Do you hear as well as you did 5 years ago?”
3. “Would you rate your hearing as excellent, good, fair, poor, or bad?”
4. “Can you tell me when you believe you started to experience a hearing loss?”
ANS: 3
During the history, it is useful to assess the client’s self-rating for a sensory deficit. You
can simply say, “Rate your hearing as excellent, good, fair, poor, or bad.” Then, based on
the client’s self-rating, explore the client’s perception of a sensory loss more fully. The
remaining options are either closed-ended questions (which do not encourage
communication) or an assumption of hearing loss.
DIF: C
REF: 1348
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
32. The primary safety issue related to the presence of a taste deficit in a young child is there
will most likely be:
1. Little incentive to hydrate
2. No social connection to food
3. Limited food experimentation
4. Little discretion for ill-tasting substances
ANS: 4
The inability to taste ill-flavored substances may well lead to accidental poisoning.
DIF: C
REF: 1350
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
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33. It has been determined that a vision problem has contributed to a client’s ability to
provide self-care regarding bathing, dressing, and toileting. The initial nursing
responsibility regarding these deficits is to:
1. Educate the client’s family regarding the existing limitations so as to secure their
support in meeting needs regarding activities of daily living (ADLs)
2. Arrange for in-home services to facilitate the client’s ability to remain as
independent as possible regarding ADLs
3. Provide the in-home care provider with sufficient information regarding the client’s
sensory deficits regarding ADLs
4. Provide sufficient client education regarding the in-home services available to help
with ADL needs once discharge has occurred
ANS: 2
If a sensory alteration impairs a client’s functional ability, providing resources within the
home is a necessary part of discharge planning. Although the other options are not
inappropriate, they are not the initial priority.
DIF: C
REF: 1349
OBJ: Analysis
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
34. The nurse is discussing eye safety with a group of adults who regularly work around
power tools. Which of the following questions should be the initial follow-up to the
nurse’s inquiry, “Do you own safety glasses?”
1. “Are they in good working order?”
2. “How long have you been using them?”
3. “Do you wear them each time you use your tools?”
4. “What do you think the advantage is to wearing them?”
ANS: 3
Although all the options are relevant to the issue of eye safety, the initial follow-up
should relate to the client’s habit of actually wearing the safety device.
DIF: C
REF: 1349
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
35. The nurse is preparing a 70-year-old visually impaired male client for home discharge.
Which of the following nursing actions will have the greatest impact on the client’s safety
related to medication administration?
1. Evaluate the client’s ability to read the frequency and dosage information on his
medication bottles.
2. Watch the client demonstrate the appropriate method for splitting his morning
medication in half.
3. Observe the client open and pour out the appropriate number of pills required for
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his morning medications.
4. Have the client restate the administration schedule and prescribed dosage of each of
his home medications.
ANS: 1
Ask the client to read a label to determine if the client is able to read the dosage and
frequency. Although the other options are appropriate interventions, the primary concern
is the ability to read the instructions in light of the visual impairment.
DIF: C
REF: 1349
OBJ: Analysis
TOP: Nursing Process: Evaluation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
36. The nurse is caring for a newly admitted client who is aphasic. The nurse most
therapeutically addresses the communication issue by:
1. Evaluating the client’s ability to express his or her needs by writing
2. Asking the client how he or she wants to communicate with the staff
3. Giving the client a pad and a pencil with which to communicate
4. Providing the client with an orientation to the use of the call bell
ANS: 2
Determine whether the client has developed a sign language system or symbols to
communicate needs. Every client should be oriented to the proper use of the call bell, and
the remaining options assume that writing will be the client’s preferred method of
communication.
DIF: C
REF: 1351
OBJ: Analysis
TOP: Nursing Process: Implementation
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
37. Which of the following statements made by the nurse shows the greatest insight into the
possible causes of a hearing-impaired client’s irritability?
1. “I know he doesn’t hear well, but I wonder if his increased lack of patience today
has to do with being in pain.”
2. “Not being able to hear us properly appears to be making him irritable today. See if
he has his hearing aid turned off.”
3. “His hearing aids must need new batteries; he is just so irritable and impatient
today.”
4. “He is certainly irritable today, but maybe it doesn’t have to do with his poor
hearing.”
ANS: 1
Always remember that factors other than sensory deprivation or overload cause impaired
perception and emotional irritation (e.g., medications or pain). Although one of the
options presents a general suspicion that the cause of the problem may not be his hearing
impairment, the remaining options assume that it is the cause of his irritation.
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DIF: C
REF: 1351
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
38. The nurse notes that the 43-year-old male blind client who has had a stroke is not having
difficulty recognizing an object by touch. This sense is known as:
1. Stereognosis
2. Auditory
3. Gustatory
4. Olfactory
ANS: 1
Stereognosis is a sense that allows a person to recognize an object’s size, shape, and
texture. The auditory sense is the sense of hearing. The gustatory sense is the sense of
tasting. The olfactory sense is the sense of smelling
DIF: C
REF: 1350
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
39. The 25-year-old male client who has been in the trauma intensive care unit (ICU) for 3
weeks is confused and agitated. The nurse knows that this can happen to clients in an ICU
setting due to:
1. Boredom
2. Sensory overload
3. Pain
4. A lack of stimulation
ANS: 2
When a person receives multiple sensory stimuli and cannot perceptually disregard or
selectively ignore some stimuli, sensory overload occurs. Excessive sensory stimulation
prevents the brain from appropriately responding to or ignoring certain stimuli. Because
of the multitude of stimuli leading to overload, the person no longer perceives the
environment in a way that makes sense
DIF: A
REF: 1349
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
40. The 85-year-old female client has moved to an assisted living apartment so that she can
remain independent yet have some limited assistance with her ADLs. Which of the
following suggestions should the nurse make that would be most appropriate to reduce
sensory deprivation?
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1. Provide pictures of the client’s family.
2. Purchase all-new furnishings.
3. Suggest that the client take all her meals in her apartment until she gets the chance
to know her neighbors better.
4. Ask family and friends to wait a few days to visit until the client has an opportunity
to settle in.
ANS: 1
Meaningful stimuli reduce the incidence of sensory deprivation. In the home, meaningful
stimuli include pets, music, television, pictures of family members, and a calendar and
clock Keeping as many of her own furnishings as possible may help make her new
environment more like home. The presence of others offers positive stimulation. The
ability to discuss concerns with loved ones is an important coping mechanism for most
people. Therefore the absence of meaningful conversation will result in feelings of
isolation, loneliness, anxiety, and depression for the client. Often, this is not apparent
until behavioral changes occur.
DIF: A
REF: 1343
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
41. A 47-year-old male client has come in to his primary health care provider’s office for his
annual checkup. The client shares with the nurse that his wife thinks he is suffering from
hearing loss. Which of the following responses by the nurse would be most appropriate?
1. "You are approaching an age when it is common to start having some hearing loss."
2. "Do you work in a noisy environment?"
3. "You don’t seem to have hearing problems to me."
4. "Has anyone else noticed that you are having hearing problems?"
ANS: 2
In the case of sensory alterations you need to integrate knowledge of the pathophysiology
of sensory deficits, factors that affect sensory function, and therapeutic communication
principles. A person’s occupation places him or her at risk for hearing, visual, and
peripheral nerve alterations. Individuals who have occupations involving exposure to
high noise levels (e.g., factory or airport workers) are at risk for noise-induced hearing
loss and need to be screened for hearing impairments. Hazardous noise is common in
work settings as well as recreational activities. Be careful to not automatically assume
that a client’s sensory problem is related to advancing age. For example, adult
sensorineural hearing loss is often due to exposure to excess and prolonged noise or
metabolic, vascular, and other systemic alterations. Collect a history that also assesses the
client’s current sensory status and the degree to which a sensory deficit affects the client’s
lifestyle, psychosocial adjustment, developmental status, self-care ability, health
promotion habits, and safety.
DIF: A
REF: 1345
TOP: Nursing Process: Assessment
OBJ: Comprehension
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MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
42. Which of the following safety measures is most important for the nurse to implement for
a hospitalized client with a visual impairment?
1. Orient the client to the room.
2. Open the window blinds to let in light.
3. Keep the client’s door to the room open so that he or she can be visualized.
4. Keep all four side rails up to remind the client not to get up on his or her own.
ANS: 1
Clients with serious visual impairment need to feel comfortable in knowing the
boundaries of the immediate environment. Normally we see physical boundaries within a
room. The blind or severely visually impaired often touch the boundaries or objects to
gain a sense of their surroundings. The client needs to walk through a room and feel the
walls to establish a sense of direction. Help clients by explaining objects within the room,
such as furniture or equipment. It takes time for the client to absorb a room’s
arrangement. The client often needs to reorient again, with your explaining the location of
key items. Glare from the window may actually cause more visual problems. The client
may prefer to have the door to the room closed for privacy. Putting all four side rails up
on the bed increases the risk for falls.
DIF: B
REF: 1344-1345
OBJ: Application
TOP: Nursing Process: Planning
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
43. Following a brain attack, the 45-year-old female client was very confused She was
having difficulty responding appropriately to the nurse and to her family members. The
client’s daughter was concerned that her mother was suffering from a mental breakdown,
even though she had no history of mental illness. The best information that the nurse can
share with the client’s daughter is:
1. "Your mother appears to have aphasia as a result of her stroke."
2. "Your mother will be just fine in no time."
3. "Your mother has been through a lot as a result of her stroke."
4. "We can have a psychiatric workup done if you would like."
ANS: 1
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The most common language disorder following a stroke is aphasia. As a result of a
disruption in blood flow to the brain, the speech center becomes damaged, altering a
person’s ability to either use or understand spoken words. Depending on the type of
aphasia, the inability to communicate is often frustrating and frightening. Initially you
need to establish very basic communication and recognize that aphasia does not indicate
intellectual impairment or degeneration of personality. Explain situations and treatments
that are pertinent to the client because he or she is able to understand the speaker’s words.
Because a stroke often causes partial or complete paralysis of one side of the client’s
body, an aphasic client will need special assistive devices. There are communication
boards that have been developed for several levels of disability. Sensitive pressure
switches, activated by the touch of an ear, nose, or chin, control electronic
communication boards. Clients who have had a stroke usually acquire referrals to speech
therapists to develop appropriate rehabilitation plans.
DIF: C
REF: 1349
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
MULTIPLE RESPONSE
1. The nurse is discussing vision changes that normally occur with aging with a group of
older adults. Which of the following conditions should be included in the discussion?
(Select all that apply.)
1. Poor night vision
2. Increased optical floaters
3. Reduced peripheral vision
4. Reduced depth perception
5. Increased sensitivity to glare
6. Diminished color perception
ANS: 1, 3, 4, 5, 6
Normal visual changes associated with aging include reduced visual fields, increased
glare sensitivity, impaired night vision, reduced depth perception, and color
discrimination. Floaters are not age related.
DIF: C
REF: 1359
OBJ: Analysis
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
2. Which of the following physical assessments are essential when attempting to determine
the presence of sensory deficits in an older adult client? (Select all that apply.)
1. Vision
2. Hearing
3. Smell
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4. Taste
5. Touch
6. Gait
ANS: 1, 2, 3, 4, 5
To identify sensory deficits and their severity, assess vision, hearing, olfaction, taste, and
the ability to discriminate light touch, temperature, pain, and position. Although gait may
be affected by a sensory deficit, it is not considered a sensory deficit by itself.
DIF: A
REF: 1359
OBJ: Comprehension
TOP: Nursing Process: Assessment
MSC: NCLEX® test plan designation: Psychosocial Integrity/Sensory/Perceptual
Alterations Systems
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