Chapter 49 – Flashcards
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stimulation of nerve cell (receptor) such as ligh, touch or sound
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Reception
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When person becomes conscious of stimuli and receives info
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Perception
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Only the most important stimuli will elicit a reaction
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Reaction
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a deficit in the normal function of sensory reception and perception
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Sensory Deficit
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a visual deficit that is a gradual decline in the ability of the lens to accomodate or to focus on close objects . Individual is unable to see near objects clearly
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Presbyopia
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a visual deficit that has cloudy or opaque areas in part of the lens or the entire lens that interfere with passage of light through the lens, causing problems with glare and blurred vision. usually develops gradually without pain redness or tearing in the eye
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Cataract
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visual deficit that results when tear glands produce too few tears resulting in itching burning or even reduced vision
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dry eyes
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a visual deficit that is a slow progressive increase in intraocular pressure that causes progressive pressure against the optic nerve, resulting in peripheral visual loss, decreased visual acuity with difficulty adapting to darkness and a halo effect around lights if left untreated
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Glaucoma
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a visual deficit that is a pathological changes in the blood vessels of the retina, resulting in decreased vision or vision loss due to hemorrhage and macular edema
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Diabetic retinopathy
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a visual deficit that is a condition in which the macula (specialized portion of the retina responsible for central vision) loses its ability to function efficiently. First sign include blurring of reading matter, distortion or loss of central vision, and distortion of vertical lines
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macular degeneration
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a Common pregressive hearing disorder in older adults
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Presbycusis
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buildup of earwax in the external auditory canal
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cerumen accumulation
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a balance deficit that is a common condition in older adulthood, usually resulting from vestibular dysfunction. Frequently a change in position of the head precipitates an episode of vertigo or disequilibrium
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Dizziness and disequilibrium
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a taste deficit that is a decrease in salivary production that leads to thicker mucus and dry mouth. often interferes with the ability to eat and leads to appetite and nutritional problems
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xerostomia
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disorder of the peripheral nervous system, characterized by symptoms that include numbness and tingling of the affected area and stumbling gait
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Peripheral neuropathy
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cerbrovascular accident caused by clot, hemorrhage, or emboli disrupting blood flow to brain. creates altered proprioception with marked incoordination and imbalance . loss of sensation and motor function in extremities controlled by affected area of brain also occurs. affecting left hemisphere of brain results in symptoms on right side such as difficulty of speech. on right brain hemisphere has symptoms on left side which includes visual spatial alterations such as loss of half of a visual field or inattention and neglect especially to left side
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stroke
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when a person experiences inadequate quality or quantity of stimulation such as monotonous or meaningless stimuli
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sensory deprivation
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when a person receives multiple sensory stimuli and cannot perceptually disregard or selectively ignore some stimuli -a person's tolarance varies by level of fatigue, attitude and emotional and physical well being
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sensory overload
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infants and children are at risk for visual and hearing impairment because of a number of genetic, prenatal and postnatal conditions.
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Age Affecting Sensory Function
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visual changes include presbyopia and need for reading glasses -pigment is lost from the iris and collagen fibers build up in teh anterior chamber, which increases risk of glaucoma by decreasing the reabsorption of intraocular fluid Hearing changes begin at age of 30 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
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Adulthood affecting Sensory Function
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common after age 60 include increased difficulty with balance spatial orientation and coordination
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Proprioceptive changes
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reduce the incidence of sensory deprivation includes pets,music,television,pictures of family member, and calendar and clock Presence of others can be positive and negative negative-roommate constantly watches television, persistently tries to talk, or continuously keeps light on will contribute to sensory overload
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Meaningful stimuli affecting sensory function
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excessive causes sensory overload. repetitive or loud noises
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Amount of Stimuli affecting sensory function
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the amount and quality with supportive family members and significant others influence sensory function
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Social Interaction affecting sensory function
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a persons occupation places him or her at risk for hearing, visual, and peripheral nerve alterations. Involving exposures to high noise levels are at risk for noise induced hearing loss and need screened -A hospitalized client is sometimes at risk for sensory alterations due to exposure or a change in sensory input. immobilized by bed rest or physical impediments unable to experience all normal sensations
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Environmental Factors affecting sensory function
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certain sensory alterations occur more commonly in select ethnic groups. Analysis of data from a recent study showed that Aleuts, Eskimos, and Native Americans have more than 3 times the rate of simultaneous hearing impairment and visual impairment relative to Asian/Pacific Islander Americans. Do not know why these groups have significantly higher , possibly because of limited health care access or combo w/ increased risks of auditory disorders and angle closure glaucoma
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Cultural Factors affecting sensory function
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improtant to first consider any pathophysiology of existing deficits, as well as all of the factors influencing, to anticipate how to approach a given clients assessment collect a history that also assesses the clients current sensory status and degree to which a sensory deficit affect clients lifestyle, psychosocial adjustment, developmental status, sel care ability, health promotion habits, and safety. assess quality and quantity of stimuli within environment
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Assessment of Sensory Function
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older adults are a high risk group b/c of normal physiological changes involving sensory organs
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Assessment of persons at risk
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when taking this, you need to consider the ethnic or cultural background of client b/c certain alterations are higher in some cultural groups assess clients self rating for sensory deficit, can also ask family
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Sensory alterations history
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an important part of any evaluation of sensory function. Observation of client during history taking, durin physical and during nursing care provides valuable data for evaluation
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Mental Status in assessing sensory function
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to identify sensory deficits and their severity assess vision hearing ,olfaction, taste, and ability to discriminate light touch, temp, pain and position
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Physical Assessment
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Assess clients functional abilities in their home environment or health care setting, including feeding, dressing, grooming, and toileting
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Ability to Perform Self Care
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assess daily routines clients follow to maintain sensory function. what type of eye and ear care is a part of clients daily hygiene
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Health Promotion Habits
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risk for injury if their living arrangements are unsafe. assess home for common hazards like, uneven cracked walkways, slippery doormats,extension and phone cords in walking area, no grab bars in RR, unmarked water faucets, Slippery RR floor, absense of smoke detectors, unlit stairways, lack of handrails, clutter, kitchen equipment with hard to read settings
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Environmental Hazards
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to understand the nature of problem, need to know wheter a client has trouble speaking, understanding, naming, reading, or writing. often develop alternative ways of communication
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communication methods
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unable to produce or understand language
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aphasia
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a motor type, the inability to name common objects or express simple ideas in words or writing
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expressive aphasia
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the inability to understand written or spokin language
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sensory or receptive aphasia
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assess if a client lives alone and whether family or friends frequently visit. Important to assess clients social skills and level of satisfaction w/ support given by family and friends
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Social Support
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assess use of assistive devices and the sensory effects for client
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Use of assistive devices
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assess history, which includes prescribed and over the counter and herbal products
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Medications
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ototoxic and permanently damage the auditory nerve
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Antibiotics
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sometimes irritates optic nerve
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Chloramphenicol
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when developing a plan of care , consider all resources available to client family plays key role in providing meaningful stimulation and learning ways to help client adjust to any limitations
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Collaborative Care
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one of most preventive sensory impairments
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Blindness
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for rubella or syphilis in women who are considering pregnancy, advocating adequate prenatal care to prevent premature birth, periodic screening of all children, especially newborns through preschoolers for congenital blindness and visual impairment
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Screening
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contact lenses, eyeglasses,hearing aids , make sure clean accessible and functional
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use of assistive devices
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normal changes of aging cause pupils ability to adjust to light diminishes, very sensitive to glare
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Promoting Meaningful stimuli of Vision
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can amplify telephones and television,
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Promoting Meaningful stimuli of Hearing
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use measures to enhance remaining taste perception. good oral hygiene, well season, differently textured food
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promoting meaningful stimuli of taste and smell
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provide touch therapy to stimulate existing function
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promoting meaningful stimuli of touch
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overly sensitive to tactile stimuli
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hyperesthesia
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provide by ensuring that name tags on uniforms are visible, addressing client by name, explaining where the client is (especially if clients are transported to different areas for treatment), and using conversational cues to time or location
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Orientation To Environment
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Most common language disorder following a stroke
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Aphasia
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use communication board or laptop
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Communications
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combine nursing activities, control extraneous noise, safety measures, reduce sensory overload
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Controlling Sensory Overload
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the client is the only person who can tell you if sensory ability has improved as a result of nursing interventions
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Evaluation
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The home health care nurse is providing instructions to a nursing assistant regarding care of an older client with visual loss. The nurse is considering normal age-related visual changes by telling the nurse assistant that clients with visual loss: A) Have better visual acuity with fluorescent lighting B) Are able to live independently in restricted environments C) Have reduced adaptation to the dark; however, peripheral vision is unchanged D) Often use colored tape to distinguish settings on electrical appliances and to highlight the edge of stairs
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The use of bright, contrasting colors help a client with diminished vision to distinguish normal visual cues. Correct Answer(s): D
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A 72-year-old client has bilateral hearing loss. She wears a hearing aid in her left ear. Which of the following approaches best facilitates communication? A) Speak directly into the client's left ear. B) Approach the client from behind and speak frequently. C) Face the client when speaking; speak slower and in a normal volume. D) Face the client when speaking; use a louder than normal voice volume.
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The nurse should face the individual with hearing loss and speak slightly slower in a normal volume. Speak a normal volume, because speaking loudly creates higher tones, and lower tones are more easily heard. The client should not be approached from behind. Speaking directly into the client's left ear deprives the client of the ability to visually participate in the conversation; her hearing aid will be effective when she is spoken to face to face. Correct Answer(s): C
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The client is a 74-year-old woman who has returned to the nursing home following surgical removal of bilateral cataracts. She reports feeling a little uncertain about walking by herself. Which of the following approaches should a nurse use to assist the client with ambulation? A) Walk one half step behind the client and slightly to the side of the client. B) If the client requires assistance, place a hand around the client's waist. C) Allow the client to stand alone in unfamiliar areas to encourage confidence building. D) Have the client grasp the nurse's arm just above the elbow and walk at a comfortable pace, warning the client when obstacles are approached
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Having the client hold the nurse's arm and then walking while warning the client of obstacles is the safest way for her to move around. The nurse should stay just in front of the client so she can be guided. Placing the hand around the client's waist is incorrect. Allowing the client to stand alone in an unfamiliar area is not an appropriate choice and can traumatize the client. Correct Answer(s): D
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Because hearing impairment is one of the most common disabilities among children, an appropriate nursing intervention is to teach parents, schoolteachers, and children to: A) Avoid activities in which crowds and loud noises occur. B) Delay childhood immunizations until hearing can be verified. C) Prophylactically administer antibiotics to reduce the incidence of ear infections. D) Take precautions when involved in activities associated with high-intensity noises
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Taking precautions to avoid high-intensity noises lessens the chance of damage to hearing. Typically, a sensory loss can be identified when a child avoids crowds. Childhood immunizations are important in the prevention of hearing loss. Prophylactic administration of antibiotics is not necessary. Antibiotics are an appropriate treatment when a bacterial infection is identified. Correct Answer(s): D
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5. The nurse is conducting discharge teaching for a client with diminished tactile sensation. Which of the following statements, if made by the client, would indicate that teaching was ineffective? A) "I may be able to dress more easily if I wear clothes with zippers or pullover sweaters." B) "I am at risk for injury from temperature extremes." C) "A home health referral may help me to achieve a maximum degree of independence." D) "I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first
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Individuals with diminished tactile sensation should dress their affected side first, then the unaffected side. The other options do not indicate ineffective teaching Correct Answer(s): D
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The nurse has completed an assessment of a 67-year-old female client who came to the clinic for the first time. During the examination the client's temperature was 37.6° C (99.6° F), heart rate was 80 beats per minute, respiration rate was 18 breaths per minute, and blood pressure was 142/84 mm Hg. The client displayed inattention as the nurse asked questions. At one point, the client seemed to shout answers to questions about her diet. However, as the nurse spoke, the client consistently smiled and nodded in agreement. The nurse's assessment indicates that the client: A) May have a visual deficit B) Is normal C) May have a hearing deficit D) Is experiencing sensory overload
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The client may not be able to hear the questions the nurse is asking and is responding to facial expressions in an attempt to continue to communicate. Correct Answer(s): C
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7. To help prevent sensory overload the nurse controls stimuli and: A) Orients the client to the environment B) Uses a communication board with the client C) Provides the client with books and a pocket magnifier D) Keeps the lights on in the client's room both day and night
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To prevent sensory overload, the nurse must make constant reorientation and control of excessive stimuli an important part of the client's care. Communication boards are typically used with clients who are unable to speak, such as clients with artificial airways or expressive aphasia. They are not used to prevent sensory overload. Books and a pocket magnifier may help provide meaningful stimuli for a client to prevent sensory deprivation, not sensory overload. Keeping the lights on all of the time will only increase the level of stimulation and thus the likelihood of developing sensory overload. Correct Answer(s): A
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8. A client was medicated for pain with a narcotic analgesic 30 minutes ago and appears drowsy. The nurse understands that teaching provided at this time may need to be reinforced later because: A) Any factor that lowers consciousness may impair perception. B) Receptor cells are now unable to transmit nerve impulses to higher centers within the brain. C) Sensory alterations will occur if an individual attempts to react to every stimulus in the environment. D) A person will stop responding to a sensory experience when the same stimulus is received over and over again.
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A person's level of consciousness influences how well stimuli are perceived and interpreted. Any factors lowering consciousness impair sensory perception. Correct Answer(s): A
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9. A nurse is conducting a teaching seminar on normal sensory changes associated with aging. The nurse realizes further education is needed when one member makes which of the following statements? A) "Older people have an increased sensitivity to glare." B) "Older people should avoid driving at dusk or at night because of impaired night vision." C) "Reduced depth perception can create a special danger for an older person walking down stairs." D) "Because older adults have reduced central vision, they are at greater risk for an accident while driving."
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Peripheral vision, not central vision, may be reduced with aging. With reduced peripheral vision a client cannot see panoramically, which creates a special hazard in driving or walking in crowded areas. Clients who drive should use rearview and side-view mirrors when changing lanes Correct Answer(s): D
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10. A client in the intensive care unit (ICU) seems withdrawn and is mumbling to herself. Her hands keep fidgeting with her intravenous (IV) tubing. Her daughter expresses concern because her mother has never acted this way before. The nurse bases her response on the knowledge that: A) Some senses may become more acute to compensate for a sensory deficit. B) Symptoms of sensory overload may include scattered attention, restlessness, and anxiety. C) Many adults are sensitive about admitting sensory losses and may hesitate to share information. D) The absence or presence of visitors has little effect on the sensory status of clients in hospital intensive care settings.
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Behavioral changes associated with sensory overload can easily be confused with mood swings or simple disorientation. The symptoms described are indicative of sensory overload. The high level of activity, lights, and noise in an ICU places a person at risk for sensory overload. Correct Answer(s): B
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11. The nurse is planning interventions to facilitate communication with a hearing-impaired client. The nurse's plan may include: A) Reducing background noise B) Speaking in high-pitched tones C) Facing the client, speaking in a louder voice, and speaking at a faster rate D) Having the client sit with other people in rows when in a group setting
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When the nurse begins a conversation with a client who has a hearing deficit, it helps to reduce any background noise by turning off or lowering the volume of any television, appliance, or radio present. Older adults hear low-pitched sounds the best. In a group setting it is better to form a semicircle in front of the client so that the client can see who is speaking; this helps foster group involvement. The nurse should face the client, speak slowly, and articulate clearly in a normal tone of voice. If it is necessary to raise the voice, the nurse should speak in lower tones (rather than shout). Correct Answer(s): A
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12. Which of the following individuals is not at risk for developing sensory deprivation? A) A client with poor vision B) A client in an intensive care unit C) A client confined to a wheelchair D) A client who is under the influence of psychotropic drugs
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The symptoms of sensory deprivation can cause nurses and physicians to believe that a client is psychologically ill and confused, is suffering from severe electrolyte imbalance, or is under the influence of psychotropic drugs. Psychotropic drugs do not increase one's risk for sensory deprivation. Correct Answer(s): D
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13. A nurse is teaching the benefits of meaningful stimuli in helping to reduce the incidence of sensory deprivation in individuals with hearing loss. The nurse knows further education is necessary when a family member makes which of the following statements? A) "We should get Mom a pet." B) "Avoiding social contact will help reduce confusion." C) "I think Mom likes the back rubs I give her when I visit." D) "I'll buy a large print calendar and a clock for Mom's bedroom."
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Clients with hearing loss tend to decrease the time spent in social activities and verbal communication. These clients are at risk for experiencing loneliness, lowered self-esteem, and sensory deprivation. Meaningful stimuli include pets, music played on a cassette player, television, pictures of family members, and a calendar and clock. Comforting touch, such as back rubs, can help prevent sensory deprivation. Correct Answer(s): B
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14. An older adult client experienced a stroke (cerebrovascular accident) and has garbled speech, although he seems to understand what is being said. The nurse recognizes this as: A) Global aphasia B) Receptive aphasia C) Perception aphasia D) Expressive aphasia
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Expressive aphasia, a motor type of aphasia, is the inability to name common objects or to express simple ideas in words or writing. The client may understand a question but be unable to express an answer. Sensory or receptive aphasia is the inability to understand written or spoken language. The client may be able to express words but is unable to understand the questions or comments of others. Global aphasia is the inability to understand language or communicate orally. There is no such thing as perception aphasia. Correct Answer(s): D
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15. A client does not seem to be paying attention during conversations with the nurse. When asked how she rates her hearing, the client states, "Poor." An appropriate nursing diagnosis may be: A) Social isolation B) Self-care deficit C) Disturbed thought processes D) Disturbed sensory perception (auditory)
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Defining characteristics for the nursing diagnosis Disturbed sensory perception (auditory) may include inattentiveness during conversations, apathy, and self-rating of hearing as "poor." The other options are nursing diagnoses that might apply to clients with sensory alterations, but the defining characteristics described in the question do not correlate with these specific diagnoses. Correct Answer(s): D
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16. Clients may be at risk for a sensory perception deficit if they: A) Keep their ears free of cerumen B) Are taking a vitamin supplement C) Have been immunized for rubella D) Have a family history of glaucoma
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People with a family history of glaucoma are at greater risk for developing the disease. Removal of cerumen can improve a client's hearing ability, not lessen it. Vitamin supplements taken as directed should not cause sensory impairment. Prevention of hearing loss includes immunization against diseases capable of causing hearing loss (e.g., rubella, mumps, and measles). Correct Answer(s): D
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17. To promote a safe living environment, an older adult client with sensory alterations should: A) Remove loose area rugs. B) Use fluorescent lighting. C) Place towels on bars in the shower. D) Have the temperature setting of the water heater no higher than 60° C (140° F).
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Loose area rugs and runners placed over carpeting are a hazard for tripping. Towels should never be placed on safety bars because they may interfere with a person's grip. As a person ages, the pupil's ability to adjust to light is diminished. As a result, older adults can be very sensitive to glare. Fluorescent lighting should be avoided. The temperature setting on the home water heater should be no higher than 49° C (120° F) to avoid accidental burns. Correct Answer(s): A
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18.The nurse is assessing a client for sensory alterations. Which of the following pieces of information would not be a significant finding suggesting risk of sensory impairment? A) African American ethnicity B) Noticeably low self-esteem C) History of having worn hearing protection devices D) Decreased involvement in social activities over the past 6 months
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The frequency and severity of glaucoma is higher in African American than in whites. A sensory deficit can cause a person to feel isolated because of an inability to communicate with others. Hearing protection devices reduce the risk of injury and are worn to prevent hearing loss by individuals exposed to high noise levels. Interacting with others can become a burden for many clients with sensory alterations. Many such clients lose the motivation to engage in social situations. Correct Answer(s): C
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19. The nurse is helping a client adjust to normal sensory changes of aging. The plan of care may include: A) Avoiding the use of shades or sheer curtains B) Painting hallways and stairwells blue, violet, or green C) Eating foods that are mixed or blended, such as casseroles, to improve flavor D) Minimizing glare by selecting satin and nongloss finishes for walls and countertops
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Normal changes associated with aging include reduced visual fields, increased glare sensitivity, impaired night vision, reduced accommodation and depth perception, and reduced color discrimination. Using nongloss finishes will help reduce glare. Shades or sheer curtains will help reduce the amount of light entering a room and therefore reduce glare. With aging, perception of the colors blue, violet, and green usually declines. Brighter colors such as red, orange, and yellow are easier to see. Hallways or stairwells should be painted so that differentiations can be made between surfaces and objects in a room. Taste perception is heightened if foods are well seasoned, differently textured, and eaten separately. Correct Answer(s): D
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21. The client has been in contact isolation for 4 days because of a gastrointestinal infection. He has had few visitors and has had few opportunities to leave his room. His ambulation is also still limited. Nursing measures to reduce sensory deprivation include which of the following? (Select all that apply.) A) Arrange for the client to have a roommate. B) Turn off the lights and close the room drapes. C) Arrange for peacefulness and frequent rest periods. D) Assist the client to a chair or bring a flower into the room. E) Sit down, speak, touch the client, and listen to the client's feelings and perceptions.
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To prevent sensory deprivation, a few small measures can help. Helping the client move around, providing visual stimulation, and providing the personal touch of spending some time with this client help minimize sensory deprivation. Correct Answer(s): D, E
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Clients with proprioceptive problems may lose their balance easily. Interventions for the nursing diagnosis risk for injury, falls may include which of the following? A) Installing grab bars in tubs and showers B) Cautioning the client against leaning backward C) Performing the majority of personal and other care for the client, including providing a sighted guide D) Changing the environmental setting frequently by rearranging the furniture
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Grab bars should be installed in tubs and showers either vertically or horizontally, depending on how the client is able to grasp or hold onto the bar. The nurse can caution the client against leaning backward. Sighted guides are used for the visually impaired. The ability to perform self-care and maintain independence is essential for self-esteem. Clients with proprioceptive problems may lose balance easily. Paths from the bed and chair to the bathroom and entrance should remain clear. Furniture should be arranged so that a client can move about easily without fear of tripping or running into objects. Constant changing of the environment may impair safety. Correct Answer(s): A, B
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23. The client has a history of a hearing deficit. He comes to the medical clinic for a routine checkup. He now reports having difficulty seeing distant objects clearly. His wife died 2 years earlier and he admits to feeling lonely much of the time. Interventions the nurse might use to reduce loneliness include which of the following? A) Reassure the client that loneliness is a normal part of aging. B) Keep one's distance while talking to avoid overstimulating the client. C) Provide information about local social groups in the client's neighborhood. D) Recommend that the client consider making living arrangements that will put him closer to family or friends.
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Providing the client with information about local social groups that he might join gives him the ability to manage his loneliness. Making other living arrangements is an option but may be too drastic an option for some clients. Loneliness does not have to be a normal part of aging. This is a client with the potential for sensory deprivation, not overstimulation. Correct Answer(s):C, D
