1. A client returning from the operating room is unconscious. What guidelines should the

NUR 108 Ch 44 Sensory Functioning

• A client returning from the operating room is unconscious. What guidelines should the

nurse consider when communicating with this client?

Talk to the client in a normal tone of voice.Gently shake the client's hand or arm before speaking to him or her.Provide loud environmental stimuli to assist in arousing the client.There are no guidelines to consider because the client cannot hear the nurse.-

Answer Talk to the client in a normal tone of voice.Explanation

As a client is recovering from unconsciousness, the nurse should assume the person can hear them.The nurse should be careful of what is said in the person's presence and speak in a normal tone of voice. Speak to the person before touching because touch is an effective means of communication but in this case, the nurse should talk to the person first.

• The nurse is working in the intensive care unit (ICU) caring for an older adult client who has

been in the unit for 2 days that is experiencing auditory and visual hallucinations. What contributing factors related to this problem does the nurse identify? Select all that apply.sensory overload sensory deprivation too much noise sleep deprivation

loneliness of environment

Answer sensory overload too much noise sleep deprivation Explanation

Severe sensory alterations can occur, especially in certain areas, such as the critical care or 1 / 3

intensive care units (termed intensive care unit [ICU] psychosis). Factors contributing to severe sensory alteration include sensory overload, sensory deprivation, sleep deprivation, and cultural care deprivation. The ICU is not an lonely environment.

• A client has just been told that he has lung cancer. The physician then describes several

potential courses of treatment to the client. When the physician leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing

Answer

sensory overload.sensory deprivation.Sensoristasis .sensory perception.sensory overload.Explanation

Sensory overload occurs when a person is unable to process or manage the intensity or quantity of incoming sensory stimuli. Imparting information to a client may lead to sensory overload. Some examples include educating a client on a procedure, informing a client about a diagnosis, making requests of a client, or helping the client solve a problem.

• The oncology nurse is caring for a client receiving chemotherapy. Which of the following

statements would be a priority assessment for the nurse?

"Have you been experiencing any strange tastes or aftertastes lately?" "Repeat the words that I will softly speak close to each ear." "Close your eyes and tell me when you feel something." "Please read my name tag."

Answer "Have you been experiencing any strange tastes or aftertastes lately?" Explanation 2 / 3

Clients receiving chemotherapy may have altered gustatory or olfactory sensations. Asking about taste would be an assessment for this condition. Repeating softly spoken words assesses auditory disturbances, feeling assesses tactile disturbances, and reading assesses visual disturbances.

• A client in a long-term care facility cannot control the direction of thought content, has a

decreased attention span, and cannot concentrate. Which effect of sensory deprivation might the client be experiencing?

Perceptual response Emotional response Physical response Cognitive response

Answer Cognitive response Explanation

Cognitive responses involve the client's inability to control the direction of thought content.Typically, attention span and ability to concentrate are decreased. Perceptual responses result from inaccurate perception of sights, sounds, tastes, smells, and body position, coordination, and equilibrium. Emotional responses typically are manifested by apathy, anxiety, fear, anger, belligerence, panic, or depression. A physical response does not relate to thought processes.

• A hospital client has been awakened at night by the alarm on his roommate's intravenous pump.

This client was aroused by brain action in his

Answer

reticular activating system (RAS).limbic system. cerebellum.prefrontal cortex.reticular activating system (RAS).Explanation

The RAS is the network that mediates arousal. The limbic system is a complex system of nerves

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