Chapter 13 Sensory Perception

Chapter 13 Sensory Perception

Complete Chapter Questions With Answers

Sample Questions Are Posted Below

MULTIPLE CHOICE. Choose the one alternative that best completes the statement or answers the question.1)A client with diabetes mellitus type 1 has a nursing diagnosis of Risk for Impaired Skin Integrityrelated to reduced tactile sensation. Outcomes are determined for the client. The primary reason forfrequent evaluation of these diagnosis-related outcomes is to determine:1)A)The competency of the nursing staff in providing quality care to the client.B)Whether to continue, modify, or terminate the plan of care.C)If the client is ready for discharge.D)The progression of the diabetes mellitus.Answer:BExplanation:A)Evaluation consists of applying measurable criteria to preset goals. It determinesthe effectiveness of nursing interventions in meeting the goals. Only by evaluatingoutcomes can the nurse decide whether to continue, modify, or terminate the goals.Evaluation does not affect the disease progression, although appropriate nursingand client actions can influence progression. The meeting of goals can be used inassessing readiness for discharge; it is not the primary reason for evaluation. Theclient’s status, not the nursing staff, is being evaluated.EvaluationSafe, Effective Care Environment-Coordinated CareApplicationB)Evaluation consists of applying measurable criteria to preset goals. It determinesthe effectiveness of nursing interventions in meeting the goals. Only by evaluatingoutcomes can the nurse decide whether to continue, modify, or terminate the goals.Evaluation does not affect the disease progression, although appropriate nursingand client actions can influence progression. The meeting of goals can be used inassessing readiness for discharge; it is not the primary reason for evaluation. Theclient’s status, not the nursing staff, is being evaluated.EvaluationSafe, Effective Care Environment-Coordinated CareApplicationC)Evaluation consists of applying measurable criteria to preset goals. It determinesthe effectiveness of nursing interventions in meeting the goals. Only by evaluatingoutcomes can the nurse decide whether to continue, modify, or terminate the goals.Evaluation does not affect the disease progression, although appropriate nursingand client actions can influence progression. The meeting of goals can be used inassessing readiness for discharge; it is not the primary reason for evaluation. Theclient’s status, not the nursing staff, is being evaluated.EvaluationSafe, Effective Care Environment-Coordinated CareApplicationD)Evaluation consists of applying measurable criteria to preset goals. It determinesthe effectiveness of nursing interventions in meeting the goals. Only by evaluatingoutcomes can the nurse decide whether to continue, modify, or terminate the goals.Evaluation does not affect the disease progression, although appropriate nursingand client actions can influence progression. The meeting of goals can be used inassessing readiness for discharge; it is not the primary reason for evaluation. Theclient’s status, not the nursing staff, is being evaluated.EvaluationSafe, Effective Care Environment-Coordinated CareApplication1
2)An elderly client with limited vision has nursing diagnoses of Activity Intolerance related todecreased oxygenation, Risk for Self-Care Deficit related to sensory-perceptual alteration, and Riskfor Social Isolation related to sensory-perceptual alteration. To address the primary nursingdiagnosis, as well as prevent or reduce the occurrence of the other two nursing diagnoses, the nurseshould most effectively plan to:2)A)Have the client decide what activities will be completed each day.B)Suggest ways that the client can decrease energy requirements during care.C)Complete all care at once to allow the client adequate rest periods.D)Space nursing activities to allow the client frequent rest periods.Answer:DExplanation:A)The priority nursing diagnosis has to be the actual problem related to decreasedoxygenation. The other two diagnoses related to sensory-perceptual alterations aresecondary priorities. The client is at risk for sensory deprivation, as well asoverload related to the limited vision and the way nurses plan the requirednursing activities. Planning nursing care to allow for adequate rest addressesactual and potential needs for all three diagnoses.PlanningPhysiological Integrity-Basic Care and ComfortAnalysisB)The priority nursing diagnosis has to be the actual problem related to decreasedoxygenation. The other two diagnoses related to sensory-perceptual alterations aresecondary priorities. The client is at risk for sensory deprivation, as well asoverload related to the limited vision and the way nurses plan the requirednursing activities. Planning nursing care to allow for adequate rest addressesactual and potential needs for all three diagnoses.PlanningPhysiological Integrity-Basic Care and ComfortAnalysisC)The priority nursing diagnosis has to be the actual problem related to decreasedoxygenation. The other two diagnoses related to sensory-perceptual alterations aresecondary priorities. The client is at risk for sensory deprivation, as well asoverload related to the limited vision and the way nurses plan the requirednursing activities. Planning nursing care to allow for adequate rest addressesactual and potential needs for all three diagnoses.PlanningPhysiological Integrity-Basic Care and ComfortAnalysisD)The priority nursing diagnosis has to be the actual problem related to decreasedoxygenation. The other two diagnoses related to sensory-perceptual alterations aresecondary priorities. The client is at risk for sensory deprivation, as well asoverload related to the limited vision and the way nurses plan the requirednursing activities. Planning nursing care to allow for adequate rest addressesactual and potential needs for all three diagnoses.PlanningPhysiological Integrity-Basic Care and ComfortAnalysis2
3)A client with Alzheimer’s disease resides in a skilled nursing facility. After a visit with the client,the client’s three adult children approach the nurse and state that their mother did not readilyrecognize one of them. What is an appropriate initial response to the family’s statement? (Select allthat apply.)3)A)”Is this the first time this has happened to any of you?”B)”Why don’t we go back into the room and see if your mother recognizes you now?”C)”This often happens with Alzheimer’s. I know it’s hard when this happens.”D)”We will make sure your mother is always safe.”E)”Which one of you did your mother not recognize?”F)”The night nurses have noticed this a couple times when your mother did not recognizethem.”Answer:A, EExplanation:A)Initially the nurse should gather more information from the family. Are therevalid reasons the client may not have recognized one of her children? This mayindicate a progression in the client’s stage of Alzheimer’s disease, particularlysince it has also been observed by the nurses during the night. Suggesting animmediate reassessment of the client’s recall of the family member may not besupportive of either the family’s or the client’s recent experience. Although safetyis always a major component of nursing care, it is not the focus of this question.AssessmentPsychosocial IntegrityApplicationB)Initially the nurse should gather more information from the family. Are therevalid reasons the client may not have recognized one of her children? This mayindicate a progression in the client’s stage of Alzheimer’s disease, particularlysince it has also been observed by the nurses during the night. Suggesting animmediate reassessment of the client’s recall of the family member may not besupportive of either the family’s or the client’s recent experience. Although safetyis always a major component of nursing care, it is not the focus of this question.AssessmentPsychosocial IntegrityApplicationC)Initially the nurse should gather more information from the family. Are therevalid reasons the client may not have recognized one of her children? This mayindicate a progression in the client’s stage of Alzheimer’s disease, particularlysince it has also been observed by the nurses during the night. Suggesting animmediate reassessment of the client’s recall of the family member may not besupportive of either the family’s or the client’s recent experience. Although safetyis always a major component of nursing care, it is not the focus of this question.AssessmentPsychosocial IntegrityApplicationD)Initially the nurse should gather more information from the family. Are therevalid reasons the client may not have recognized one of her children? This mayindicate a progression in the client’s stage of Alzheimer’s disease, particularlysince it has also been observed by the nurses during the night. Suggesting animmediate reassessment of the client’s recall of the family member may not besupportive of either the family’s or the client’s recent experience. Although safetyis always a major component of nursing care, it is not the focus of this question.AssessmentPsychosocial IntegrityApplication3
E)Initially the nurse should gather more information from the family. Are therevalid reasons the client may not have recognized one of her children? This mayindicate a progression in the client’s stage of Alzheimer’s disease, particularlysince it has also been observed by the nurses during the night. Suggesting animmediate reassessment of the client’s recall of the family member may not besupportive of either the family’s or the client’s recent experience. Although safetyis always a major component of nursing care, it is not the focus of this question.AssessmentPsychosocial IntegrityApplicationF)Initially the nurse should gather more information from the family. Are therevalid reasons the client may not have recognized one of her children? This mayindicate a progression in the client’s stage of Alzheimer’s disease, particularlysince it has also been observed by the nurses during the night. Suggesting animmediate reassessment of the client’s recall of the family member may not besupportive of either the family’s or the client’s recent experience. Although safetyis always a major component of nursing care, it is not the focus of this question.AssessmentPsychosocial IntegrityApplication