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24 Cards in this Set

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The nurse begins sensory alterations history by asking the client to describe the sensory deficit
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?
What is the most important defining characteristics for the nursing diagnosis of disturbed sensory perception?
the client's self-rating for hearing
Assessment of Mental Status: Physical Appearance and Behavior
Motor activity, posture, facial expression, hygiene
Assessment of Mental Status: Cognitive Ability
Level of consciousness, abstract reasoning, calculation, attention, judgment; Ability to carry on conversation, ability to read, write, and copy figure; Recent and remote memory
Assessment of Mental Status: Emotional Stability
Agitation, euphoria, irritability, hopelessness, or wide mood swings; Auditory, visual, or tactile hallucinations, illusions, delusions
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:
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?
Common hazards that can be problematic to clients with sensory alterations
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
Aphasia
unable to produce or understand language
Expressive aphasia
a motor type of aphasia, is the inability to name common objects or to express simple ideas in words or writing
Receptive aphasia
is the inability to understand written or spoken language
To understand the nature of a communication problem, the nurse must know whether
a client has trouble speaking, understanding, naming, reading, or writing
Some antibiotics are _ and can permanently the auditory nerve
ototoxic
Examples of nursing diagnosis for client that has sensory alterations
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
Three recommended interventions for visual impairment
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
Refractive errors
referred to as nearsightedness
_ _ is one of the most common disabilities in the US
hearing impairment
Children at risk include
those with a family history of childhood hearing impairment, perinatal infection (rubella, herpes, cytomegalovirus), low birth weight, chronic ear infection, and Down syndrome
The loss of hearing in young adults 20 to 30 years old is attributed to
exposure to noise at constantly high levels, such as from portable music devices, automobile music systems, concerts, and loud music in aerobics classes
In the US, _ is the second leading cause of blindness in the general population and primary cause of blindness in African-Americans
glaucoma
Clients between ages 40 and 62 are recommended to eye exams every
2 to 4 years
Eye Exams should occur every 1 to 2 years if
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
_ is a common cause of blindness in children
trauma
Adults are at risk for eye injury while
playing sports and working in jobs involving exposure to chemicals or flying objects
A client who wears corrective contacts lenses, eyeglasses, or hearing aids should make sure they are
kept clean, accessible, and functional