Sensory Alterations From Ch 48

Front 1

The nurse begins sensory alterations history by asking the client to describe the sensory deficit

Back 1

Describe your hearing loss for me; Describe how your vision is affected; Explain how use of your hands has changed; Knowledge about the onset and duration of the sensory alteration can be helpful; How long have you had a visual problem?; When did you begin to feel numbness in your hands?; In your legs?; How long have you noticed being unable to hear conversations clearly?

Front 2

What is the most important defining characteristics for the nursing diagnosis of disturbed sensory perception?

Back 2

the client's self-rating for hearing

Front 3

Assessment of Mental Status: Physical Appearance and Behavior

Back 3

Motor activity, posture, facial expression, hygiene

Front 4

Assessment of Mental Status: Cognitive Ability

Back 4

Level of consciousness, abstract reasoning, calculation, attention, judgment; Ability to carry on conversation, ability to read, write, and copy figure; Recent and remote memory

Front 5

Assessment of Mental Status: Emotional Stability

Back 5

Agitation, euphoria, irritability, hopelessness, or wide mood swings; Auditory, visual, or tactile hallucinations, illusions, delusions

Front 6

A nursing history can also reveal any recent changes in a client's behavior. Friends and family are the best resources for this info, because the client may be unaware of any changes. The nurse can asks the following:

Back 6

Has the client shown any recent mood swings (e.g., outbursts of anger, nervousness, fear, or irritability)? Have you noticed the client avoiding social activities?

Front 7

Common hazards that can be problematic to clients with sensory alterations

Back 7

Uneven, cracked walkways leading to front/back door, Extension and phone cords in the main route of walking traffic, Doormats with slippery backing, Loose area rugs and runners placed over carpeting, Bathrooms without shower or tub grab bars, Water faucets unmarked to designate hot and cold, Bathroom floor with slippery surface, Absence of smoke detectors in rooms, Unlit stairways, lack of handrails, Cluttered floors, furniture, including footstools

Front 8

Aphasia

Back 8

unable to produce or understand language

Front 9

Expressive aphasia

Back 9

a motor type of aphasia, is the inability to name common objects or to express simple ideas in words or writing

Front 10

Receptive aphasia

Back 10

is the inability to understand written or spoken language

Front 11

To understand the nature of a communication problem, the nurse must know whether

Back 11

a client has trouble speaking, understanding, naming, reading, or writing

Front 12

Some antibiotics are _ and can permanently the auditory nerve

Back 12

ototoxic

Front 13

Examples of nursing diagnosis for client that has sensory alterations

Back 13

Impaired adjustment; Impaired verbal communications; Risk for injury; Impaired physical mobility; Self-care deficit, bathing/hygiene; Self-care deficit, dressing/grooming; Situational low self-esteem; Disturbed sensory perception; Social isolation; Disturbed thought processes

Front 14

Three recommended interventions for visual impairment

Back 14

1. screening for rubella or syphilis in women who are considering pregnancy 2. adequate prenatal care to prevent premature birth 3. periodic screening of all children, especially newborns through preschoolers, for congenital blindness and visual impairment caused by refractive errors and strabismus

Front 15

Refractive errors

Back 15

referred to as nearsightedness

Front 16

_ _ is one of the most common disabilities in the US

Back 16

hearing impairment

Front 17

Children at risk include

Back 17

those with a family history of childhood hearing impairment, perinatal infection (rubella, herpes, cytomegalovirus), low birth weight, chronic ear infection, and Down syndrome

Front 18

The loss of hearing in young adults 20 to 30 years old is attributed to

Back 18

exposure to noise at constantly high levels, such as from portable music devices, automobile music systems, concerts, and loud music in aerobics classes

Front 19

In the US, _ is the second leading cause of blindness in the general population and primary cause of blindness in African-Americans

Back 19

glaucoma

Front 20

Clients between ages 40 and 62 are recommended to eye exams every

Back 20

2 to 4 years

Front 21

Eye Exams should occur every 1 to 2 years if

Back 21

there is a family history of glaucoma or if the client is of African ancestry, has had a serious eye injury in the past, is taking steroid medications, or is over 65 years of age

Front 22

_ is a common cause of blindness in children

Back 22

trauma

Front 23

Adults are at risk for eye injury while

Back 23

playing sports and working in jobs involving exposure to chemicals or flying objects

Front 24

A client who wears corrective contacts lenses, eyeglasses, or hearing aids should make sure they are

Back 24

kept clean, accessible, and functional