Chapter 44 Sensory

The nurse is assessing a client’s gustatory function. What approach by the nurse will assist in assessing this sensation

• “Tell me if the taste on your tongue is sweet, sour, bitter, or salty.”

• “Repeat the words that I speak softly to you.”

• “Please read this paragraph to me.”

• “Close your eyes and tell me what you smell.”

Answer explanation

Gustatory sensations equate to taste. Repeating words assesses auditory function. Reading a paragraph assesses visua disturbances. Smelling assesses for olfactory disturbances.

What term is used to describe the sense, usually at a subconscious level, of the movements and position of the body (especially its limbs) independent of vision?

• Stereognosis

• Visceral

• Proprioception

• Sensory perception

Answer explanation

Proprioception describes the sense, usually at a subconscious level, of the movements and position of the body (especially its limbs) independent of vision. Stereognosis is the perception of the solidity, size, shape, and texture of body parts. Visceral refers to inner organs and reception. Sensory perception is the conscious process of selecting, organizing, and interpreting data from the senses into meaningful information.

A client says, “What is that awful smell?” What sense is being used?

• Olfactory

• Gustatory

• Tactile

• Auditory

Answer explanation

The senses by which a person maintains contact with the external environment are vision (visual), hearing (auditory), smell (olfactory), taste (gustatory), and touch (tactile).

Which of the following best describes a stimulus?

• A sense organ that receives a message and converts it into a nerve impulse

• Conduction along a nerve pathway from the receptor to the brain

• Reception and translation of an impulse into a sensation

• An act or agent that initiates a response by the nervous system

Answer explanation

For a person to receive the necessary data to experience the world, there must first be a stimulus. A stimulus is an agent, act, or other influence capable of initiating a response by the nervous system.

After assessing a client, a nurse documents the state of awareness as confused. What part of the brain controls awareness?

• Cranial nerves

• Reticular activating system

• Hypothalamus

• Medulla

Answer explanation

To receive stimuli and respond appropriately, the brain must be alert or aroused. The reticular activating system (RAS) mediates arousal.

How would a nurse document the condition in which a client has a normal state of awareness?

• “Aware of self and environment, responsive, well-oriented.”

• “Easily distracted, alternates between drowsiness and excitability.”

• “Disoriented, restless, agitated, hallucinating.”

• “Can’t be aroused and does not respond to stimuli.”

Answer explanation

A normal state of awareness is one in which there is awareness of self and the external environment, including being well-oriented and responsive.

A nurse documents the following on a client chart: “client manifests difficulties with spatial orientation, memory language, and changes in personality.” What state of arousal/awareness does this describe?

• Delirium

• Dementia

• Confusion

• Locked-in syndrome

Answer explanation

Difficulties with spatial orientation, memory, language, and changes in personality occur with delirium. Disorientation, restlessness, confusion, hallucinations, and agitation, alternating with other conscious states, occurs with dementia. In confusion, the client manifests reduced awareness, is easily distracted, easily startled by sensory stimuli, and alternates between drowsiness and excitability. In locked-in syndrome, the client displays full consciousness, sleep–wake cycles are present, and auditory and visual function and emotions are preserved.

Which of the following hospital units is more likely to cause severe sensory alterations?

• General unit

• Short-stay surgery

• Eye clinic

• Intensive care

Answer explanation

Severe sensory alterations can occur when a client is admitted to a health care agency, especially in certain areas such as intensive care units (termed intensive care unit [ICU] psychosis).

In which of the following health care settings is a client more likely to be at risk for sensory deprivation?

• Hospital newborn nursery

• Community health center

• Emergency department

• Long-term care

Answer explanation

Sensory deprivation occurs when a client experiences decreased sensory input or input that is monotonous, unpatterned, or meaningless. In this question, clients in long-term care would be most at risk for sensory deprivation.

What type of cognitive responses might a nurse assess in a client with sensory deprivation?

• Uncoordinated movements, altered sense of smell

• Decreased attention span, difficulty problem solving

• Apathy, depression

• Rapid mood changes, anxiety

Answer explanation

Cognitive responses to sensory deprivation include an inability to control thoughts, decreased attention span, and difficulty with memory, problem solving, and task performance.