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  Potter & Perry: Fundamentals of Nursing, 7 th  Edition Test Bank Chapter 4: !ensory lterations#$%TP%E C'(CE 1.During a community screening, the nurse informs a 50-year-old African American client about the frequency of eye examinations. It is recommended that individuals in this age-grou have eye examinations!1. very # to $ months%. very & months#. very 1 to % years$. very $ yearsA'(!#)lients bet*een the ages of $0 and &$ should have an eye examination every 1 to % years if there is a family history of glaucoma or if the client is of African ancestry.DI+!A +!1#55/!)omrehension!'ursing rocess! Imlementation2()!')3 4 test lan designation! sychosocial Integrity6(ensory6ercetual Alterations (ystems%.7ith advancing age, *hich of the follo*ing normal hysiological changes in sensory function occurs81.Decreased sensitivity to glare%.Increased number of taste buds#.Difficulty discriminating vo*el sounds$.Decreased sensitivity to ainA'(!$lder adults exerience tactile changes, including declining sensitivity to ain, ressure, and temerature. lder adults have an increased sensitivity to glare. lder adults have a decreased number of taste buds. lder adults have difficulty discriminating the consonants 9  z,   t,    f,    g  : and high-frequency sounds 9s, sh, h, ;:.DI+!A +!1#$&/!)omrehension!'ursing rocess! Assessment2()!')3 4 test lan designation! sychosocial Integrity6(ensory6ercetual Alterations (ystems#.he nurse teaches a client that rolonged use of the antibiotic stretomycin may result in!1.Damage to the auditory nerve%.Alteration in ercetion#.tic irritation$.3oss of taste 2osby items and derived items < %00=, %005 by 2osby, Inc., an affiliate of lsevier Inc.  est an; A'(!1(ome antibiotics, such as stretomycin, gentamicin, and tobramycin, are ototoxic and can ermanently damage the auditory nerve. 'arcotic analgesics, sedatives, and antideressant medications can alter the ercetion of stimuli. )hloramhenicol can irritate the otic nerve.DI+!A +!1#51/!)omrehension!'ursing rocess! Imlementation2()!')3 4 test lan designation! sychosocial Integrity6(ensory6ercetual Alterations (ystems$.7hich of the follo*ing occuations oses the least ris; for sensory alterations81.7aiter %.7elder #.)omuter rogrammer $.)onstruction *or;er A'(!1he *aiter is at least ris; for sensory alterations. A *elder is at ris; for visual alterations. A comuter rogrammer is at ris; for eriheral nerve in>ury. A construction *or;er is at ris; for hearing alterations.DI+!A +!1#5&/!)omrehension!'ursing rocess! Assessment2()!')3 4 test lan designation! sychosocial Integrity6(ensory6ercetual Alterations (ystems5.he nurse is *or;ing *ith a client *ith a moderate hearing imairment. o romote communication *ith this client, the nurse should!1.?se a louder tone of voice than normal%.?se visual aids such as the hands and eyes *hen sea;ing #.Aroach a client quietly from behind before sea;ing$.(elect a ublic area to have a conversationA'(!%o romote communication *ith the client *ho has a hearing imairment, the nurse should use visible exressions, such as sea;ing *ith the hands, face, or eyes. A normal tone of voice and inflections of seech should be used *hen communicating *ith a client *ith a hearing imairment. he nurse should get the client@s attention and not startle the client *hen entering a room. he nurse should not aroach a client from behind. It is  best to select a quiet environment *ithout bac;ground noise to facilitate communication *hen a client is hearing imaired.DI+!A +!1#5/!)omrehension!'ursing rocess! lanning2()!')3 4 test lan designation! sychosocial Integrity6(ensory6ercetual Alterations (ystems 2osby items and derived items < %00=, %005 by 2osby, Inc., an affiliate of lsevier Inc. $=-%  est an; &.he client has hyeresthesia aarently associated *ith a neurological trauma. 7hich of the follo*ing is an aroriate nursing intervention in regard to the client@s sense of touch81.eminding the client of the need to have frequent tactile contact%.Beeing the client loosely covered *ith sheets and blan;ets#.Allo*ing the client to lie motionless $.?sing touch as a form of therayA'(!%If a client is overly sensitive to tactile stimuli 9hyeresthesia:, the nurse must minimiCe irritating stimuli. Beeing bed linens loose to minimiCe direct contact *ith the client and  rotecting the s;in from exosure to irritants are helful measures. +requent tactile contact is not an aroriate intervention for the client *ith hyeresthesia. Allo*ing the client to lie motionless is not an aroriate intervention for the client *ith hyeresthesia.?sing touch as a form of theray *ould not be an aroriate nursing intervention for theclient *ith hyeresthesia.DI+!A +!1#5/!)omrehension!'ursing rocess! lanning2()!')3 4 test lan designation! sychosocial Integrity6(ensory6ercetual Alterations (ystems.he client has exerienced a cerebral vascular accident 9stro;e: *ith resultant exressive ahasia. he nurse romotes communication *ith this client by!1.(ea;ing very loudly and slo*ly%.(ea;ing to the client on the unaffected side#.?sing a icture chart for the client@s resonses$.?sing hand gestures to convey information to the clientA'(!#+or the client *ith ahasia, the nurse can communicate using a icture chart or communication board for the client@s resonses. he nurse should not sea; loudly and slo*ly to the client *ith exressive ahasia. he client is able to understandE this may seem atroniCing to the client. he nurse should not sea; to the client on the unaffected side, as this *ill not imrove communication. ?sing hand gestures to convey informationto the client may be helful for the client *ith recetive ahasia, not exressive ahasia.DI+!A +!1#50/!)omrehension!'ursing rocess! Imlementation2()!')3 4 test lan designation! sychosocial Integrity6(ensory6ercetual Alterations (ystems.he client *as *or;ing in the ;itchen and *as slashed in the face *ith a caustic cleaning agent. Fis eyes *ere affected, and he *as brought to the hosital for treatment. After cleansing and evaluation, his eyes *ere bandaged. 7hen assisting this client, *ho has temorary visual loss, to eat the nurse should! 2osby items and derived items < %00=, %005 by 2osby, Inc., an affiliate of lsevier Inc. $=-#  est an; 1.+eed the client the entire meal%.Allo* the client to exeriment *ith foods#.rient the client to the location of the foods on the late$.Assign ancillary ersonnel to feed the clientA'(!#A meal tray can be set u as a cloc;. he visually imaired client can easily become oriented to the items after the nurse or family member exlains each item@s location. his enables the client to erform self-care 9feeding:, *hich is essential for self-esteem. he client should be allo*ed to feed himself to maintain self-esteem. Allo*ing the client to exeriment *ith foods is not assisting the client in erforming self-care. he client should be allo*ed to feed himself to maintain self-esteem.DI+!A +!1#&1/!)omrehension!'ursing rocess! Imlementation2()!')3 4 test lan designation! sychosocial Integrity6(ensory6ercetual Alterations (ystems=.he nurse comletes a safety assessment during a home visit to an older adult client. f the follo*ing observations made by the nurse, the one that is of greatest concern for this client *ho has evidence of sensory imairment is!1.3o*-ile careting throughout the home%.A handrail on the stairs that extends the full length#.Figher *attage incandescent lighting in all the rooms$.he gray6blac; settings on the stove handlesA'(!$(ometimes settings on electrical aliances and equiment are only highlighted in blac; and *hite or shades of gray. )olor contrasts hel to distinguish settings. he greatest concern for safety for the client *ith sensory imairment is the gray6blac; setting on the stove handles. 3o*-ile careting hels to revent falls. A handrail on the stairs that extends the full length is beneficial for reventing falls. Figher *attage incandescent lighting hels revent glare and is an aroriate adatation for visual loss.DI+!) +!1#5&/!Analysis!'ursing rocess! Assessment2()!')3 4 test lan designation! sychosocial Integrity6(ensory6ercetual Alterations (ystems10.A client is legally blind in both eyes. 7hich of the follo*ing is the most aroriate statement for the nurse to ma;e to the client regarding roviding the client *ith assistance81.GI *ill *al; in front of you, and you can hold onto my belt.H%.GI ;no* that you must need me to be your sighted guide to get around in this facility.H#.GI *ill *arn you of ucoming curbs or stairs.H$.GI *ill get you a *heelchair so that I can move you around safely.H 2osby items and derived items < %00=, %005 by 2osby, Inc., an affiliate of lsevier Inc. $=-$
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