Kozier & Erb’s Fundamentals of Nursing, 10/E
Chapter 38
Question 1
Type: MCSA
During review of admission data, the nurse learns that the new client has impairment of kinesthetic sensation.
Which nursing intervention should be planned for this client?
1. Use the clock face as a format for describing the position of food on meal trays.
2. Provide all teaching materials in very large font.
3. Ensure that the client has assistance when ambulating.
4. Use only nonirritating soaps for bathing.
Question 2
Type: MCSA
A client diagnosed with congestive heart failure has been treated for many years with intravenous furosemide
(Lasix). What sensory impairment should the nurse assess in this client?
1. Loss of ability to taste
2. Hearing loss
3. Vision loss
4. Loss of ability to smell
Question 3
Type: MCSA
A client has been treated for diabetes mellitus since childhood. Currently, the client’s blood glucose reading is
180 mg/dl. For which sensory disturbance should the nurse assess in this client?
1. Loss of ability to taste
2. Hearing loss
3. Vision loss
4. Loss of ability to smell
Question 4
Type: MCSA
The nurse suspects that the client has a hearing disorder; however, the client denies not being able to hear. What
initial assessment technique should the nurse employ?
1. Schedule a Weber and Rinne test.
2. Observe the client’s interaction with significant others.
3. Use an otoscope to visualize the inner ear.
4. Confront the client with the nurse’s suspicion.
Question 5
Type: MCSA
The nurse is providing education for the parents of a 7-month-old child who has just been diagnosed with a
hearing loss. What guidance should the nurse provide?
1. Expect that the child will be enrolled in a special hearing intervention program immediately.
2. Keep your child in a quiet environment until additional testing is done.
3. Interventions to support hearing are not useful until the child is at least 9 months old.
4. Hearing loss is not serious until 1 year of age.
Question 6
Type: MCSA
The odor from a hospitalized client’s draining wound permeates the room and is very overwhelming and
distracting to the client and the staff. What intervention would be most helpful?
1. Spray the room routinely with a floral room spray.
2. Instill a vinegar solution into the wound.
3. Keep the wound dressing dry and clean.
4. Burn a candle in the room.
Question 7
Type: MCSA
The nurse is assisting a visually impaired client with ambulation. How should the nurse proceed with this
intervention?
1. Walk slightly behind the client.
2. Walk 1 foot in front of the client.
3. Walk on the right side of the client.
4. Walk on the left side of the client.
Question 8
Type: MCSA
An older client has become very confused since being hospitalized earlier in the week. Prior to this illness, the
client exhibited clear thought processing and was able to maintain an independent lifestyle. How should the nurse
document this mental state?
1. As reversible confusion
2. As sundown syndrome
3. As delirium
4. As dementia
Question 9
Type: MCMA
The nurse is concerned that a client is not aware of being in the hospital. For what aspects of the sensory process
should the nurse assess the client?
Standard Text: Select all that apply.
1. Speech
2. Stimuli
3. Receptor
4. Perception
5. Impulse conduction
Question 10
Type: MCSA
A client can be aroused only with extreme or repeated stimuli. How should the nurse document this client’s
behavior?
1. Somnolent
2. Disoriented
3. Comatose
4. Semicomatose
Question 11
Type: MCSA
The nurse is planning care for a client who is experiencing dementia. What essential concept should the nurse
consider for this planning?
1. Background noise such as music will keep this client calm.
2. Activities should be scheduled at the same time each day.
3. Pain mediation will increase dementia.
4. It is important to talk with the client throughout procedures.
Question 12
Type: MCSA
The client who has the medical diagnosis of Alzheimer’s disease is confused and has difficulty interpreting
environmental stimuli. Which nursing diagnosis problem statement most accurately describes this client’s
situation?
1. Acute Confusion
2. Altered Role Performance
3. Disturbed Sensory Perception
4. Disturbed Thought Processes
Question 13
Type: MCSA
The nurse is caring for a client who has difficulty hearing conversation. What intervention should the nurse
implement?
1. Use short phrases.
2. Overarticulate words.
3. Vary the volume of the voice.
4. Face the client during conversation.
Question 14
Type: MCMA
A client is experiencing changes in taste. What can the nurse do to improve this client’s gustatory sense?
Standard Text: Select all that apply.
1. Suggest eating each food separately.
2. Offer foods with a variety of flavors.
3. Recommend eating foods that are cold.
4. Promote sips of water between eating different foods.
5. Encourage the client to consume foods of different textures.
Question 15