Sensory Perception
Name the six senses included in sensory perception.
What are vision, hearing, touch, smell, taste, and position/movement (kinesthetic/proprioception)?
List at least five expected findings that may indicate a vision problem.
What are headaches, eye strain, blurred vision, diplopia (double vision), poor depth perception, favoring one eye, and poor hand-eye coordination?
State the primary focus of end-of-life care.
What are comfort, dignity, symptom control, and emotional support rather than curing disease?
How long does one complete sleep cycle last, and what two stages alternate throughout the cycle?
What is approximately 90–110 minutes, alternating between NREM and REM sleep?
A nurse prepares to suction a client with a tracheostomy. The client’s SpO₂ is 89%, respirations are labored, and coarse crackles are heard. Before inserting the catheter, the nurse should perform this intervention first.
What is hyperoxygenating the client?
Compare sensory deprivation and sensory overload by describing the cause, common assessment findings, and nursing interventions for each.
What is sensory deprivation (insufficient stimulation causing depression, withdrawal, confusion, hallucinations, and decreased attention; managed with communication, family visits, music, glasses/hearing aids, ROM, massage, pleasant scents, and varied textures) and sensory overload (excessive stimulation causing anxiety, restlessness, irritability, fatigue, insomnia, and difficulty concentrating; managed by reducing noise, dimming lights, limiting visitors, clustering care, promoting rest, and using orientation cues)?
List the nursing teaching points for administering eye medications and the additional teaching required after receiving anticholinergic eye drops.
What are wash hands before and after administration, avoid touching the dropper tip, wait about 5 minutes between different eye medications, remove contact lenses if instructed, wear sunglasses after dilation, and avoid driving until vision returns to normal?
Identify the four advance care planning documents or decisions that help ensure a patient's wishes are honored.
What are an advance directive, living will, durable power of attorney for healthcare, and a Do Not Resuscitate (DNR) order?
Compare the three stages of NREM sleep by describing the major characteristics of each.
What are NREM Stage 1 (very light sleep, easily awakened, muscle relaxation begins, heart rate slows), Stage 2 (light sleep, heart rate and body temperature decrease, harder to awaken, greatest percentage of total sleep), and Stage 3 (deepest sleep, difficult to awaken, lowest heart rate and blood pressure, physical restoration and growth hormone release)?
A nurse prepares to suction a tracheostomy client. The client asks, "Why do you have to check my oxygen level first?" The nurse explains that suctioning can cause this complication.
What is decreased oxygen saturation/hypoxia?
Identify at least six nursing interventions when communicating with a client who has hearing loss.
What are gain the client's attention, face the client directly, keep your mouth visible, speak slowly and clearly, use a lower vocal pitch, do not shout, use short simple sentences, reduce background noise, write information if needed, and provide an ASL interpreter when appropriate?
Compare cataracts, glaucoma, and macular degeneration by identifying the affected eye structure, hallmark finding, and major complication of each.
What are cataracts (clouding of the lens causing blurred vision and glare; treated with cataract surgery), glaucoma (increased intraocular pressure damaging the optic nerve and potentially causing permanent blindness), and macular degeneration (degeneration of the macula causing loss of central vision while peripheral vision is usually preserved)?
Identify the expected respiratory changes that commonly occur during the dying process.
What are irregular breathing, Cheyne-Stokes respirations, decreased respiratory rate, and noisy secretions ("death rattle")?
Identify the three types of insomnia and describe how they differ.
What are acute insomnia (lasting a few days to weeks, often related to stress), chronic insomnia (occurring at least three nights per week for three months or longer), and intermittent insomnia (alternating periods of insomnia and normal sleep)?
A nurse uses a Yankauer suction catheter on an alert client who can cough independently. The nurse knows this procedure requires this type of technique.
What is medical asepsis (clean technique)?
List four common causes of vision loss.
What are presbyopia, cataracts, glaucoma, diabetic retinopathy, macular degeneration, eye infection, eye injury, brain tumors, or stroke?
This age-related vision disorder is caused by decreased elasticity of the lens, making it difficult to focus on nearby objects.
What is presbyopia?
List at least eight nursing interventions that promote comfort for a patient receiving end-of-life care.
What are administering pain medication as prescribed, repositioning for comfort, providing frequent oral care, keeping the patient clean and dry, managing dyspnea with positioning and oxygen if indicated, reducing unnecessary interventions, providing a calm and quiet environment, encouraging family presence if desired, and respecting cultural and spiritual preferences?
List at least eight factors that can interfere with sleep.
What are pain, nocturia, sleep apnea, dyspnea, fever, anxiety, stress, fear, depression, grief, shift work, travel, irregular schedules, heavy meals before bedtime, caffeine, alcohol, vigorous exercise before bedtime, noise, bright lights, uncomfortable temperatures, frequent interruptions, nicotine, and substance use?
A client has excessive respiratory secretions requiring frequent cleaning. Which tracheostomy design would best meet this client’s needs?
What is a double-lumen tracheostomy tube with a removable inner cannula?
Match each sensory deficit with one important home safety intervention: visual, hearing, olfactory, taste, and tactile.
What are visual deficits—remove throw rugs, improve lighting, install handrails, use contrasting colors; hearing deficits—use flashing alarms, visual doorbells, captioned phones/TV; olfactory deficits—install smoke and carbon monoxide detectors and remove spoiled food; taste deficits—check expiration dates, practice oral hygiene, use herbs and spices; tactile deficits—avoid heating pads, test bath water temperature, protect numb extremities, and inspect the skin daily?
Identify at least eight health promotion strategies that help preserve vision and hearing.
What are wearing sunglasses outdoors, following the 20-20-20 rule, avoiding rubbing the eyes, scheduling routine eye exams after age 40, controlling blood pressure, blood glucose, and cholesterol, stopping smoking, limiting alcohol, eating antioxidant-rich foods, never inserting cotton swabs into the ear canal, wearing hearing protection around loud noise, keeping headphone volume low, blowing the nose gently, and having foreign objects removed by a healthcare provider
Explain the goals of hospice care, including who qualifies, where it may be provided, and its overall focus.
What is hospice care for clients with a life expectancy of approximately six months or less, available at any age and provided at home, in hospice facilities, nursing homes, or hospitals, with a focus on comfort, symptom management, emotional and family support, and a peaceful, natural dying process rather than curative treatment?
Compare narcolepsy and hypersomnolence disorder, including defining characteristics and management strategies for each.
What is narcolepsy (a neurologic disorder causing sudden sleep attacks and excessive daytime sleepiness, managed with scheduled naps, exercise, high-protein meals, stimulant medications, and avoiding driving when sleepy) and hypersomnolence disorder (persistent excessive daytime sleepiness despite adequate nighttime sleep for at least three months, managed with a regular sleep schedule, adequate nighttime sleep, and stimulant medications)?
A nurse notices the cuff pressure on a tracheostomy tube has been elevated for several hours. The nurse knows this places the client at risk for this injury.
What is tracheal tissue necrosis?