The family of a client in the hospital is concerned about the constant noise in the care area. Which health care
professionals have the greatest control over the level of sensory input in the hospital?
1. Physicians
2. Administrators
3. Nurses
4. Planners
Question 16
Type: MCMA
The nurse documents that a client is fully conscious. What did the nurse assess in this client?
Standard Text: Select all that apply.
1. Client responded to verbal stimuli.
2. Client responded to written words.
3. Client oriented to time, place, and person.
4. Client demonstrated poor memory.
5. Client alert.
Question 17
Type: MCSA
A client asks the nurse to please close the door when entering or exiting the room because the noise is more than
the client is used to because he lives alone. The nurse identifies the reason for this client’s response to sensory
stimuli as being due to which factor?
1. Lifestyle
2. Developmental stage
3. Culture
4. Illness
Question 18
Type: MCMA
The nurse is concerned that a client is experiencing sensory deprivation. What did the nurse assess to make this
clinical decision?
Standard Text: Select all that apply.
1. Excessive sleeping
2. Confusion at night
3. Anger over minor issues
4. Easily distracted
5. Sitting quietly reading a book
Question 19
Type: MCMA
The nurse suspects a client will develop sensory overload. What characteristics did the nurse observe in the client?
Standard Text: Select all that apply.
1. Ongoing pain
2. Confusion at night
3. Inability to sleep
4. Easily angered
5. Worrying about upcoming diagnostic tests
Question 20
Type: MCSA
A client is hospitalized for treatment of a new disorder. While admitted, the client receives no telephone calls or
visitors. The nurse should assess which aspect of the client’s sensory-perception function?
1. Risk for sensory overload
2. Social support network
3. Mental status
4. Environment
Question 21
Type: MCMA
The nurse is assessing a client for possible sensory deprivation. What findings would indicate the client is at risk
for developing this sensory disorder?
Standard Text: Select all that apply.
1. Client has severe pain.
2. Client has impaired vision.
3. Client is unable to ambulate.
4. Client is on medication that alters sensory perception.
5. Client has no family in the immediate area.
Question 22
Type: MCSA
The nurse is identifying diagnoses appropriate for a client recovering from cataract surgery who lives alone.
Which diagnosis would be the priority for this client?
1. Social Isolation
2. Risk for Impaired Skin Integrity
3. Disturbed Sensory Perception
4. Risk for Injury
Question 23
Type: MCSA
The nurse is identifying outcome criteria for a client with a nursing diagnosis of Disturbed Sensory Perception,
Auditory. What would indicate that interventions to address this diagnosis have been successful?
1. Client places hearing aid on beside table when not in use.
2. Client does not respond appropriately to questions.
3. Client demonstrates use and care of hearing aid.
4. Client demonstrates difficulty with problem solving.
Question 24
Type: MCMA
A client is experiencing acute confusion. What nursing actions would be appropriate for this client?
Standard Text: Select all that apply.
1. Eliminate unnecessary noise.
2. Keep eyeglasses within reach.
3. Place a calendar in the room, and identify each day.
4. Keep the room well lit during waking hours.
5. Provide dark glasses.
Question 25
Type: MCMA
Which recent change, reported by a client’s family, would indicate that the client’s hearing ability is decreasing?
Standard Text: Select all that apply.
1. Inability to follow directions
2. Mood swings
3. Decreased appetite
4. Complaints of dizziness
5. Answering questions incorrectly
Question 26
Type: MCMA
The nurse is concerned that a hospitalized client is experiencing sensory overload. What did the nurse assess to
come to this conclusion?
Standard Text: Select all that apply.
1. Sleeplessness
2. Anxiety
3. Apathy
4. Racing thoughts
5. Somatic complaints