Sensory Function Case Study with Rationale
Q. Which action should the nurse take first?
(Rationale) As the lipid accumulates, the cornea may look thickened and raised. The assessment finding should be documented in the electronic medical record
Q. How will the nurse assess for the presence of tinnitus?
(Rationale) Tinnitus is the presence of ringing in the ears, which is often associated with hearing loss.
Q. To follow up this situation, which assessment will provide the most useful data?
(Rationale) Under- or over-reaching for objects is an indication of a visual deficit. Assessment of visual field and depth perception will provide the most useful data related to this situation.
Q. How should the nurse explain these findings to Frank?
(Rationale) The larger the denominator (bottom number), the poorer the visual acuity. This is commonly referred to as being near-sighted. Standing at 20 feet, the client can read what the person with normal vision can read at further distances, such as 80 feet (right eye) or 200 feet (left eye).
Q. Which nursing diagnosis is best supported by the data available?
(Rationale) Clients with impaired hearing often smile and nod in agreement with the person conversing even though they are unable to clearly hear the conversation. Appearing to be inattentive, speaking loudly, and difficulty following directions are other indications of a disturbance in auditory sensory function.
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(Rationale) The assessment data is compared with the defining characteristics of the problem to ensure that the correct problem is identified.
Q. When evaluating for hearing loss, which questions should the RN ask Frank? (SELECT ALL THAT APPLY)
(Rationale) the RN wants to know the onset of the hearing loss. Presbycusis is the term for gradual onset of hearing loss which is usually worse in noisy environments.
*Has your hearing decreased or do you just hear certain sounds?
(Rationale) The RN is assessing the character of the hearing loss with the question. A marked loss is at low intensity but sound actually becomes painful when the speaker repeats in a loud voice.
*Do ordinary sounds sound like you are under water?
(Rationale) The RN is assisting the character of hearing loss. Asking if the client has recently traveled by airplane or had an upper respiratory infection would be useful information to obtain.
*How does the hearing loss affect your life?
(Rationale) by asking the client about coping strategies, the RN is collecting subjective data. Hearing loss can cause social isolation and decreased quality of life and lead to functional and cognitive decline and depression.
Q. Which action should the RN assessing Frank implement?
(Rationale) Clients with a hearing impairment have difficulty hearing the conversation when there is background noise, such as music or other conversations.
Q. Which direction should the nurse provide Frank?
(Rationale) These are the correct directions.
Q. Which action should the nurse take?
(Rationale) The outer canthus is not held during the administration of eye drops. The conjunctival sac at the bottom of the eye is pulled downward so the medication can be administered without directly applying it to the cornea.
Q. Which action should the nurse implement?
(Rationale) This is the best intervention to reduce Frank’s risk for injury. The nurse can provide a home safety checklist as a reference to ensure that Frank’s home is safe for a person with sensory deficits.
Q. What is the best response by the nurse?
(Rationale)The client with a visual deficit may trip on loose edges, cords, wet spots, or unexpected items left on the floor. Explaining the rationale for desired actions, such as the removal of throw rugs, increases client compliance.
Q. Which action should the nurse implement?
(Rationale) The nurse needs to recognize the reasons behind the client’s angry outburst and provide a therapeutic response, such as presence and silence.
Q. How should the nurse demonstrate a caring response to Frank?
(Rationale) Active listening includes giving full attention to what the client is saying and provides a caring presence.
Q. Which nursing diagnosis should be added to the plan of care?
(Rationale) The nurse’s analysis of Frank’s behavior reflects the fear that he may become dependent on others, creating feelings of diminished self-esteem.
After the second round of chemotherapy, the nurse’s assessment reveals that Frank has lost ten pounds. Frank states that smells make him sick to his stomach, and his food has no taste. To improve Frank’s appetite, friends often cook meals for him in his home, keeping the foods soft and bland.
Q. What client teaching should the nurse provide?
(Rationale) The addition of seasonings, such as lemon juice, enhances food flavor and stimulates taste sensation.
(Rationale) Removing the aroma of cooking food eliminates a major trigger for the client with a heightened sense of smell.
Q. How will the nurse document this finding?
(Rationale) Paresthesia refers to abnormal sensation, including sensations such as burning, numbness, or tingling.
Q. What technique should the nurse use?
(Rationale) After the client closes his eyes, the nurse touches the extremities with items that are hot, cold, sharp, and dull. The client identifies the sensation felt, which assesses discrimination of sensation.
Q. What color tape is best for Frank to use to label his hot water faucets?
(Rationale) As people age, their ability to distinguish color diminishes. Safety hazards should be marked with colors that are easy to distinguish, such as orange, red, or yellow.
Frank’s paresthesia has not diminished in his hands. The nurse starts an IV prior to his surgery, but the IV infiltrates. The nurse places a heating pad over Frank’s arm and hand to reduce the swelling, but forgets to remove the pad. Another nurse later removes the pad and notes small blisters on Frank’s palms as the result of the heating pad being left in place too long.
Q. What is the legal significance of this situation?
(Rationale) The application of heat is a procedure based on set standards of care for which the nurse is accountable. Malpractice occurs when the care provided by a professional does not meet those standards of care. Additionally, the nurse is responsible to recognize that this client is at high risk for injury related to his altered sensation (paresthesia) and therefore to take the necessary precautions to prevent injury.
(Rationale) The nurse documents the client’s symptoms and actions taken, including notification of the healthcare provider, prescriptions received, interventions implemented, and follow-up evaluation.
After surgery, Frank is transferred to a room on the Surgical Unit near the nursing station. In the middle of the night, Frank awakens and seems restless and confused. The room is dark except for the light that filters in through the almost totally closed door to the hallway.
Q. Which nursing action will best reduce Frank’s confusion?
(Rationale)The client with sensory impairment may become easily confused in a strange environment, especially at night when influenced by postoperative pain and medications. The nurse should reorient the client, speaking with a calm and reassuring voice.
Q. When leaving the room, which action should the nurse implement?(SELECT ALL THAT APPLY)
*Ensure Frank can easily reach the call bell.
(Rationale) A small amount of indirect lighting will enable the client to identify the surroundings upon awakening, reducing confusion without providing excessive sensory stimulation.
Frank tells the nurse that his grandson has taken over the family farm. Frank remarks, “I guess he’ll be hard of hearing too someday. It’s happened to all the farmers in my family.”
Q. How should the nurse respond?
(Rationale) This response enhances physiologic integrity for the client’s family member and is proactive health promotion and disease prevention. Although hearing loss may have a genetic component, it is often preventable as in this situation involving Frank’s grandson.
Q. Which question should the nurse ask Frank to learn about any risk factors that his grandson’s children may have?
(Rationale) Chronic middle ear infection is associated with hearing loss. Additionally, clients should be aware that medications, such as some antibiotics and large doses of aspirin, can be ototoxic.