1. 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 lightingB) Are able to live independently in restricted environmentsC) Have reduced adaptation to the dark; however, peripheral vision is unchangedD) Often use colored tape to distinguish settings on electrical appliances and to highlight the edge of stairs

Feedback: INCORRECT The use of bright, contrasting colors help a client with diminished vision to distinguish normal visual cues.Points Earned: 0.0/1.0

Correct Answer(s):D

2. 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.

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):C

3. 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.

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):D

4. 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.

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):D

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.

Feedback: INCORRECT Individuals with diminished tactile sensation should dress their affected side first, then the unaffected side. The other options do not indicate ineffective teaching.Points Earned: 0.0/1.0

Correct Answer(s):D

6. 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 deficitB) Is normalC) May have a hearing deficitD) Is experiencing sensory overload

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):C

7. To help prevent sensory overload the nurse controls stimuli and:A) Orients the client to the environmentB) Uses a communication board with the clientC) Provides the client with books and a pocket magnifierD) Keeps the lights on in the client's room both day and night

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):A

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.

Feedback: INCORRECT A person's level of consciousness influences how well stimuli are perceived and interpreted. Any factors lowering consciousness impair sensory perception.Points Earned: 0.0/1.0

Correct Answer(s):A

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."

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):D

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.

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):B

11. The nurse is planning interventions to facilitate communication with a hearing-impaired client. The nurse's plan may include:A) Reducing background noiseB) Speaking in high-pitched tonesC) Facing the client, speaking in a louder voice, and speaking at a faster rateD) Having the client sit with other people in rows when in a group setting

Feedback: INCORRECT 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).Points Earned: 0.0/1.0

Correct Answer(s):A

12. Which of the following individuals is not at risk for developing sensory deprivation?A) A client with poor visionB) A client in an intensive care unitC) A client confined to a wheelchairD) A client who is under the influence of psychotropic drugs

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):D

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."

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):B

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 aphasiaB) Receptive aphasiaC) Perception aphasiaD) Expressive aphasia

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):D

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 isolationB) Self-care deficitC) Disturbed thought processesD) Disturbed sensory perception (auditory)

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):D

16. Clients may be at risk for a sensory perception deficit if they:A) Keep their ears free of cerumenB) Are taking a vitamin supplementC) Have been immunized for rubellaD) Have a family history of glaucoma

Feedback: INCORRECT 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).Points Earned: 0.0/1.0

Correct Answer(s):D

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).

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):A

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 ethnicityB) Noticeably low self-esteemC) History of having worn hearing protection devicesD) Decreased involvement in social activities over the past 6 months

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):C

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 curtainsB) Painting hallways and stairwells blue, violet, or greenC) Eating foods that are mixed or blended, such as casseroles, to improve flavorD) Minimizing glare by selecting satin and nongloss finishes for walls and countertops

Feedback: INCORRECT 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.Points Earned: 0.0/1.0

Correct Answer(s):D

20. A nurse considering the effect of sensory function on an individual's level of wellness knows which of the following facts?A) There is no direct relationship between the two.B) If sensory alterations occur early in life, clients will have little difficulty with socialization.C) Alterations in hearing and vision can place a person at risk for injury; the other senses have little impact on one's safety.D) When sensory function is altered, the person's ability to relate to and function within the environment changes drastically.

Feedback: INCORRECT Humans rely on a variety of sensory stimuli to give meaning and order to events occurring in their environment. Being able to process meaningful stimuli with the senses allows people to learn about the environment and is necessary for healthy functioning and normal development. If sensory alterations occur early in life, clients often have developmental and socialization problems because of difficulty in responding to people and the environment. Reduced olfaction places clients at risk because they may be unable to smell leaking gas, a smoldering cigarette or fire, or tainted food. Clients with reduced tactile sensation are at risk for injury from exposure to temperature extremes.Points Earned: 0.0/1.0

Correct Answer(s):D

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.

Feedback: INCORRECT 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.Points Earned: 0.0/2.0

Correct Answer(s):D, E

22. 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 showersB) Cautioning the client against leaning backwardC) Performing the majority of personal and other care for the client, including providing a sighted guideD) Changing the environmental setting frequently by rearranging the furniture

Feedback: INCORRECT 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.Points Earned: 0.0/2.0

Correct Answer(s):A, B

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.

Feedback: INCORRECT 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.Points Earned: 0.0/2.0

Correct Answer(s):C, D