Sensory Function Case Study with Rationale – Flashcards
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During the initial interview, the nurse inspects the external anatomy of the eye. The eye is a sensory organ of vision, and it is well protected by a bony orbital cavity and surrounded with a cushion of fat. The RN notes tat the cornea looks cloudy and an arcus senilis is seen around the cornea. Q. Which action should the nurse take first?
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A. Assess whether the cornea looks thickened and raised and document the finding. (Rationale) As the lipid accumulates, the cornea may look thickened and raised. The assessment finding should be documented in the electronic medical record
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During the assessment of Frank's hearing, the nurse performs a series of tests, including Frank's ability to hear whispered and conversational tones. Q. How will the nurse assess for the presence of tinnitus?
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A. Ask the client if he ever hears ringing in his ears. (Rationale) Tinnitus is the presence of ringing in the ears, which is often associated with hearing loss.
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Frank seems nervous and asks for a glass of water. After taking a drink, he attempts to set the glass down, but places the glass on the edge of the counter, causing it to crash to the floor. Q. To follow up this situation, which assessment will provide the most useful data?
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A. Visual field and depth perception. (Rationale) Under- or over-reaching for objects is an indication of a visual deficit. Assessment of visual field and depth perception will provide the most useful data related to this situation.
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Frank's visual acuity is measured using a Snellen chart. The reading obtained is 20/80 in the right eye and 20/200 in the left eye. Q. How should the nurse explain these findings to Frank?
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A. "You are very near-sighted, especially in your left eye." (Rationale) The larger the denominator (bottom number), the poorer the visual acuity. This is commonly referred to as being near-sighted. Standing at 20 feet, the client can read what the person with normal vision can read at further distances, such as 80 feet (right eye) or 200 feet (left eye).
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As the interview continues, the nurse notes that Frank is very pleasant and nods his head in agreement with all of the nurse's statements, but that he often does not respond to simple requests during the assessment. Q. Which nursing diagnosis is best supported by the data available?
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A. Disturbed sensory alteration (auditory). (Rationale) Clients with impaired hearing often smile and nod in agreement with the person conversing even though they are unable to clearly hear the conversation. Appearing to be inattentive, speaking loudly, and difficulty following directions are other indications of a disturbance in auditory sensory function.
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Q. In identifying this problem, the nurse clustered the assessment data and compared it with which information?
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A. Defining characteristics of the problem. (Rationale) The assessment data is compared with the defining characteristics of the problem to ensure that the correct problem is identified.
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The RN plans to assess subjective data about Frank's hearing loss. Q. When evaluating for hearing loss, which questions should the RN ask Frank? (SELECT ALL THAT APPLY)
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A. *Did hearing loss occur gradually or all at once? (Rationale) the RN wants to know the onset of the hearing loss. Presbycusis is the term for gradual onset of hearing loss which is usually worse in noisy environments. *Has your hearing decreased or do you just hear certain sounds? (Rationale) The RN is assessing the character of the hearing loss with the question. A marked loss is at low intensity but sound actually becomes painful when the speaker repeats in a loud voice. *Do ordinary sounds sound like you are under water? (Rationale) The RN is assisting the character of hearing loss. Asking if the client has recently traveled by airplane or had an upper respiratory infection would be useful information to obtain. *How does the hearing loss affect your life? (Rationale) by asking the client about coping strategies, the RN is collecting subjective data. Hearing loss can cause social isolation and decreased quality of life and lead to functional and cognitive decline and depression.
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Music is playing loudly through the exam room's intercom system. Another RN enters the room and turns the music off before speaking with Frank. Q. Which action should the RN assessing Frank implement?
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A. Affirm that the other RN's action may assist Frank's ability to hear by eliminating background noise. (Rationale) Clients with a hearing impairment have difficulty hearing the conversation when there is background noise, such as music or other conversations.
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Frank is referred to vision and hearing specialists for more in-depth evaluation and treatment. A medical diagnosis of cataracts is identified as the cause of Frank's visual deficit. Noise-induced hearing loss, as well as changes related to aging, are identified as the causes of Frank's auditory deficit. Frank is scheduled for eye surgery in three weeks. The nurse teaches Frank about the administration of the eye drops he will need to administer. The prescription states, "2 gtts in left eye twice a day." Q. Which direction should the nurse provide Frank?
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A. Place two drops in the left eye every 12 hours. (Rationale) These are the correct directions.
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Frank demonstrates the eye drop procedure by holding the outer canthus up and back, inserting the drops without touching the eye with the dropper, and applying light pressure over the inner canthus. Q. Which action should the nurse take?
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A. Teach the client to pull the conjunctival sac down while administering the medication. (Rationale) The outer canthus is not held during the administration of eye drops. The conjunctival sac at the bottom of the eye is pulled downward so the medication can be administered without directly applying it to the cornea.
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After learning to self-administer eye drops, Frank is preparing to go home. The nurse has identified that Frank is at risk for injury because of his visual and auditory sensory deficits. Q. Which action should the nurse implement?
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A. Make plans with Frank for a family member to help him assess his home for safety hazards. (Rationale) This is the best intervention to reduce Frank's risk for injury. The nurse can provide a home safety checklist as a reference to ensure that Frank's home is safe for a person with sensory deficits.
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Frank reports to the nurse that he feels his home is free of hazards. He states he does have some decorative throw rugs on top of his hardwood floors, but they can't slide because there is padding underneath them that prevents sliding. Q. What is the best response by the nurse?
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A. "Even though the rugs don't slide, you might trip over the loose edges." (Rationale)The client with a visual deficit may trip on loose edges, cords, wet spots, or unexpected items left on the floor. Explaining the rationale for desired actions, such as the removal of throw rugs, increases client compliance.
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Frank becomes angry after the nurse provides the list of home safety checks that should be performed and suggests he remove his throw rugs. He yells, "You think I'm a helpless old man and can't take care of myself anymore!" Q. Which action should the nurse implement?
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A. Stay in the room, sitting with the client. (Rationale) The nurse needs to recognize the reasons behind the client's angry outburst and provide a therapeutic response, such as presence and silence.
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The nurse recognizes that Frank is fearful and angry. Q. How should the nurse demonstrate a caring response to Frank?
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A. Give full attention to what the client is saying. (Rationale) Active listening includes giving full attention to what the client is saying and provides a caring presence.
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The nurse interprets Frank's angry outburst as an indication that he is afraid he may become dependent upon others if his sensory deficits continue. Q. Which nursing diagnosis should be added to the plan of care?
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A. Disturbed situational low self-esteem. (Rationale) The nurse's analysis of Frank's behavior reflects the fear that he may become dependent on others, creating feelings of diminished self-esteem.
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During the preoperative evaluation for Frank's cataract surgery, a chest x-ray reveals a small mass in Frank's left lung. A biopsy reveals that the mass is cancerous. Frank's cataract surgery is postponed, and he begins chemotherapy. After the second round of chemotherapy, the nurse's assessment reveals that Frank has lost ten pounds. Frank states that smells make him sick to his stomach, and his food has no taste. To improve Frank's appetite, friends often cook meals for him in his home, keeping the foods soft and bland. Q. What client teaching should the nurse provide?
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A. Add seasonings to the bland food to stimulate the taste buds. (Rationale) The addition of seasonings, such as lemon juice, enhances food flavor and stimulates taste sensation.
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Q. What additional teaching can the nurse provide to reduce the problems related to Frank's sense of smell?
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A. Suggest that the meals be prepared at the friends' homes and then delivered to Frank ready to eat. (Rationale) Removing the aroma of cooking food eliminates a major trigger for the client with a heightened sense of smell.
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Frank reports that his fingers often feel numb, or like "pins and needles." Assessment reveals 3+ radial pulses bilaterally with capillary refill of 1 second. Q. How will the nurse document this finding?
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A. Parasthesia. (Rationale) Paresthesia refers to abnormal sensation, including sensations such as burning, numbness, or tingling.
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The nurse plans to assess Frank's ability to discriminate sensation. Q. What technique should the nurse use?
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A. Touch the extremities with items, and ask Frank to describe the sensation felt. (Rationale) After the client closes his eyes, the nurse touches the extremities with items that are hot, cold, sharp, and dull. The client identifies the sensation felt, which assesses discrimination of sensation.
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The nurse tells Frank that his altered touch sensation is the result of his chemotherapy. The nurse is concerned about home safety while Frank's ability to discriminate sensation is diminished. The nurse suggests that Frank label all his hot water fixtures with tape for easy identification. Frank agrees this is a good idea since his plumbing fixtures are old and the "C" and "H" have faded. Q. What color tape is best for Frank to use to label his hot water faucets?
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A. Orange. (Rationale) As people age, their ability to distinguish color diminishes. Safety hazards should be marked with colors that are easy to distinguish, such as orange, red, or yellow.
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Frank has completed his chemotherapy and is now scheduled for surgery to remove the mass. Frank's paresthesia has not diminished in his hands. The nurse starts an IV prior to his surgery, but the IV infiltrates. The nurse places a heating pad over Frank's arm and hand to reduce the swelling, but forgets to remove the pad. Another nurse later removes the pad and notes small blisters on Frank's palms as the result of the heating pad being left in place too long. Q. What is the legal significance of this situation?
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A. The nurse who applied the heating pad has demonstrated malpractice. (Rationale) The application of heat is a procedure based on set standards of care for which the nurse is accountable. Malpractice occurs when the care provided by a professional does not meet those standards of care. Additionally, the nurse is responsible to recognize that this client is at high risk for injury related to his altered sensation (paresthesia) and therefore to take the necessary precautions to prevent injury.
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Q. Which documentation is important for the nurse to include in the client's medical record regarding the unfortunate situation with the heating pad?
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A. Management of the client's blisters. (Rationale) The nurse documents the client's symptoms and actions taken, including notification of the healthcare provider, prescriptions received, interventions implemented, and follow-up evaluation.
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Frank is taken to the operating room, and the mass is successfully removed. After surgery, Frank is transferred to a room on the Surgical Unit near the nursing station. In the middle of the night, Frank awakens and seems restless and confused. The room is dark except for the light that filters in through the almost totally closed door to the hallway. Q. Which nursing action will best reduce Frank's confusion?
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A. Address the client by name, stating where the client is and what time it is. (Rationale)The client with sensory impairment may become easily confused in a strange environment, especially at night when influenced by postoperative pain and medications. The nurse should reorient the client, speaking with a calm and reassuring voice.
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The nurse's action calms Frank. Q. When leaving the room, which action should the nurse implement?(SELECT ALL THAT APPLY)
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A. *Turn on the bathroom light. *Ensure Frank can easily reach the call bell. (Rationale) A small amount of indirect lighting will enable the client to identify the surroundings upon awakening, reducing confusion without providing excessive sensory stimulation.
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The remainder of Frank's hospitalization is uneventful, and he prepares for discharge. Discharge teaching includes a review of home safety measures since Frank continues to experience auditory and visual sensory deficits. Frank tells the nurse that his grandson has taken over the family farm. Frank remarks, "I guess he'll be hard of hearing too someday. It's happened to all the farmers in my family." Q. How should the nurse respond?
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A. Advise the client to tell his grandson to use protective hearing devices whenever he is working with loud machinery to preserve his hearing. (Rationale) This response enhances physiologic integrity for the client's family member and is proactive health promotion and disease prevention. Although hearing loss may have a genetic component, it is often preventable as in this situation involving Frank's grandson.
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Because Frank's grandson is in his early twenties and has a young family of his own, the nurse also provides Frank with a client teaching booklet about hearing impairment in children that he can give to his grandson. Q. Which question should the nurse ask Frank to learn about any risk factors that his grandson's children may have?
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A. "Do any of the children experience frequent ear infections?" (Rationale) Chronic middle ear infection is associated with hearing loss. Additionally, clients should be aware that medications, such as some antibiotics and large doses of aspirin, can be ototoxic.
