10TYK. An 85-year-old client has impaired hearing. When creating the care plan, which intervention should have the highest priority?
1. Obtaining an amplified telephone
2. Teaching the importance of changing his position
3. Providing reading material with large print
4. Checking expiration dates on food packages
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1CTC. Mrs. Dodd is a 51-year-old client who is being cared for in the critical care unit following an automobile crash in which she suffered extensive traumatic injuries. Mrs. Dodd is connected to several monitoring devices, has an intubation tube and ventilator to assist her with respirations, and is receiving various pain and other medications.
Identify factors that place Mrs. Dodd at risk for the development of sensory deprivation or overload.
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1TYK. Which client is at greatest risk for experiencing sensory overload?
1. A 40-year-old client in isolation with no family
2. A 28-year-old quadriplegic client in a private room
3. A 16-year-old listening to loud music
4. An 80-year-old client admitted for emergency surgery
Get Solution
2CTC. Mrs. Dodd is a 51-year-old client who is being cared for in the critical care unit following an automobile crash in which she suffered extensive traumatic injuries. Mrs. Dodd is connected to several monitoring devices, has an intubation tube and ventilator to assist her with respirations, and is receiving various pain and other medications.
What hat assessment findings would alert you to Mrs. Dodd’s expe- riencmg sensory overload as opposed to sensory deprivation?
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2TYK. An alert 80-year-old client is transferred to a long-term care facility. On the second night, he becomes restless and agitated. What is the most appropriate nursing diagnosis?
1. Chronic Confusion
2. Impaired Memory
3. Acute Confusion
4. Disturbed Thought Processes
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3CTC. Mrs. Dodd is a 51-year-old client who is being cared for in the critical care unit following an automobile crash in which she suffered extensive traumatic injuries. Mrs. Dodd is connected to several monitoring devices, has an intubation tube and ventilator to assist her with respirations, and is receiving various pain and other medications.
How can you intervene to help Mrs.Dodd during this stressful event?
Get Solution
3TYK. The nursing diagnosis Risk for Impaired Skin Integrity related to sensory-perception disturbance would best fit a client who:
1. Cut a foot by stepping on broken glass.
2. Uses a wheelchair due to paraplegia.
3. Wears glasses because of poor vision.
4. Is legally blind and smokes in bed.
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4CTC. Mrs. Dodd is a 51-year-old client who is being cared for in the critical care unit following an automobile crash in which she suffered extensive traumatic injuries. Mrs. Dodd is connected to several monitoring devices, has an intubation tube and ventilator to assist her with respirations, and is receiving various pain and other medications.
How might the care of a client in the home setting differ from the care of a client such as Mrs. Dodd who is receiving care in a critical care unit?
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4TYK. Which statement indicates the client needs a sensory aid in the home?
1. “I tripped over that throw rug again.”
2. “I can’t hear the doorbell.’’
3. “My eyesight is good if I wear my glasses.”
4. “I can hear the TV if I turn it up high.”
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5TYK. A hospitalized client is disoriented and believes she is in a train station. Which response from the nurse is the most appropriate?
1. “You wouldn’t be getting a bath at the train station.”
2. “Let’s finish your bath before the train arrives.”
3. “Don’t you know where you are?”
4. “It may seem like a train station sometimes, but this is Valley Hospital.”
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6TYK. A client with impaired vision is admitted to the hospital. Which interventions are most appropriate to meet the client’s needs? Select all that apply.
1. Identify yourself by name.
2. Decrease background noise before speaking.
3. Stay in the client’s field of vision.
4. Explain the sounds in the environment
Get Solution
7TYK. A client is exhibiting signs and symptoms of acute confusion/ delirium-Which strategy should the nurse implement to promote a therapeutic environment?
1 Keep lights in the room dimmed during the day to decrease stimulation.
2 Keep the environmental noise level high to increase stimulation.
3. Keep the room organized and clean.
4, Use restraints for client safety.
Get Solution
8TYK. A client is at risk for sensory deprivation. Which of the following clinical signs would the nurse observe? Select all that apply.
1. Sleeplessness
2. Decreased attention span
3. Irritability
4. Excessive sleeping
5. Crying, depression
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9TYK. The nurse is assessing for sensory function. Match the assessment tool to the specific sense it will be testing.
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1. Obtaining an amplified telephone
2. Teaching the importance of changing his position
3. Providing reading material with large print
4. Checking expiration dates on food packages
Get Solution
1CTC. Mrs. Dodd is a 51-year-old client who is being cared for in the critical care unit following an automobile crash in which she suffered extensive traumatic injuries. Mrs. Dodd is connected to several monitoring devices, has an intubation tube and ventilator to assist her with respirations, and is receiving various pain and other medications.
Identify factors that place Mrs. Dodd at risk for the development of sensory deprivation or overload.
Get Solution
1TYK. Which client is at greatest risk for experiencing sensory overload?
1. A 40-year-old client in isolation with no family
2. A 28-year-old quadriplegic client in a private room
3. A 16-year-old listening to loud music
4. An 80-year-old client admitted for emergency surgery
Get Solution
2CTC. Mrs. Dodd is a 51-year-old client who is being cared for in the critical care unit following an automobile crash in which she suffered extensive traumatic injuries. Mrs. Dodd is connected to several monitoring devices, has an intubation tube and ventilator to assist her with respirations, and is receiving various pain and other medications.
What hat assessment findings would alert you to Mrs. Dodd’s expe- riencmg sensory overload as opposed to sensory deprivation?
Get Solution
2TYK. An alert 80-year-old client is transferred to a long-term care facility. On the second night, he becomes restless and agitated. What is the most appropriate nursing diagnosis?
1. Chronic Confusion
2. Impaired Memory
3. Acute Confusion
4. Disturbed Thought Processes
Get Solution
3CTC. Mrs. Dodd is a 51-year-old client who is being cared for in the critical care unit following an automobile crash in which she suffered extensive traumatic injuries. Mrs. Dodd is connected to several monitoring devices, has an intubation tube and ventilator to assist her with respirations, and is receiving various pain and other medications.
How can you intervene to help Mrs.Dodd during this stressful event?
Get Solution
3TYK. The nursing diagnosis Risk for Impaired Skin Integrity related to sensory-perception disturbance would best fit a client who:
1. Cut a foot by stepping on broken glass.
2. Uses a wheelchair due to paraplegia.
3. Wears glasses because of poor vision.
4. Is legally blind and smokes in bed.
Get Solution
4CTC. Mrs. Dodd is a 51-year-old client who is being cared for in the critical care unit following an automobile crash in which she suffered extensive traumatic injuries. Mrs. Dodd is connected to several monitoring devices, has an intubation tube and ventilator to assist her with respirations, and is receiving various pain and other medications.
How might the care of a client in the home setting differ from the care of a client such as Mrs. Dodd who is receiving care in a critical care unit?
Get Solution
4TYK. Which statement indicates the client needs a sensory aid in the home?
1. “I tripped over that throw rug again.”
2. “I can’t hear the doorbell.’’
3. “My eyesight is good if I wear my glasses.”
4. “I can hear the TV if I turn it up high.”
Get Solution
5TYK. A hospitalized client is disoriented and believes she is in a train station. Which response from the nurse is the most appropriate?
1. “You wouldn’t be getting a bath at the train station.”
2. “Let’s finish your bath before the train arrives.”
3. “Don’t you know where you are?”
4. “It may seem like a train station sometimes, but this is Valley Hospital.”
Get Solution
6TYK. A client with impaired vision is admitted to the hospital. Which interventions are most appropriate to meet the client’s needs? Select all that apply.
1. Identify yourself by name.
2. Decrease background noise before speaking.
3. Stay in the client’s field of vision.
4. Explain the sounds in the environment
Get Solution
7TYK. A client is exhibiting signs and symptoms of acute confusion/ delirium-Which strategy should the nurse implement to promote a therapeutic environment?
1 Keep lights in the room dimmed during the day to decrease stimulation.
2 Keep the environmental noise level high to increase stimulation.
3. Keep the room organized and clean.
4, Use restraints for client safety.
Get Solution
8TYK. A client is at risk for sensory deprivation. Which of the following clinical signs would the nurse observe? Select all that apply.
1. Sleeplessness
2. Decreased attention span
3. Irritability
4. Excessive sleeping
5. Crying, depression
Get Solution
9TYK. The nurse is assessing for sensory function. Match the assessment tool to the specific sense it will be testing.
| Identifying taste | 1. Visual |
| Stereognosis | 2. Hearing |
| Snellen chart | 3. Tactile |
| Identifying aromas | 4. Olfactory |
| Tuning fork | 5. Gustatory |
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