week 3
sensory ____ is the ability to receive and interpret sensory impressions through sight ( visual), hearing ( auditory), touch (tactile), smell ( olfactory), taste (gustatory), and movement or position (kinesthetic).
perception
sensory ___ affects consciousness, arousal, awareness, memory, affect, judgment, awareness of reality , and language
input
A sensory ___ is a change in reception and/or perception. deficits can affect any of the senses. when this sensory develops gradually, the body often compensates for the deficit.
deficit
sensory ___ is reduced sensory input from the internal or external environment. it can result from illness trauma or isolation. manifestation of this sensory can be cognitive ( decreased ability to learn disorientation), affective ( restlessness, anxiousness), or perceptual (decreased coordination, decreased color perception).
deprivation
sensory ___ is excessive, sustained, and unmanageable multisensory stimulation. manifestations are similar to those of sensory deprivation and include racing thoughts, anxiousness, and restlessness.
overload
xerostomia or reduced salivation ; alters appetite
Taste deficit
Peripheral neuropathy ; peripheral numbness
Neurologic deficits
Can result in loss of sensation , difficulty speaking ( aphasia ) , and visual deficits
stroke
is a medical term used to describe the temporary cessation or pause in breathing.
apnea
What advice should the nurse provide to a client who is taking medication for anxiety-induced insomnia?
Avoid activity that require alertness
The SBAR tool is a structured method of communication used by
healthcare professionals to effectively and efficiently communicate
client information. S stands for Situation, B stands for ____. A
stands for
Assessment, and R stands for Recommendattor.
background
In the intensive care unit with multiple medical devices beeping, a client experiencing intense pain is most likely to experience sensory ___
overload
Which could be a sign of complication of immobilization?
constipation
A medical device with clear plastic chamber with a piston and a series of markers indicating different levels of lung volume, used to help clients improve their lung function, is called incentive
spirometer
Which client complaint from an elderly immobile client may indicate a complication of immobility
Stiffness of extremity Joints
Isometric exercise involves tightening or contracting a muscle group without movement of the ___
joint
What is the movement of a body part towards the midline of the body called?
adduction
Exposure to light can suppress the section of __ which is a hormone that helps regulate sleep, so turning off the light can help promote its secretion and support the clients natural sleep awake cycle
melatonin
The nurse is assisting a client on the three-point gait for ambulating with crutches where the left and right crutch along with the __leg are both advanced, while the unaffected leg supports the body weight
affected
A chronic sleep disorder characterized by overwhelming daytime drowsiness and sudden attacks of sleep is called----------.
Narcolepsy
Which complication of prolonged immobility should be given the highest priority?
Atelectasis
Which client statement indicates understanding of the purpose of his new order for sequential compression device?
This device will keep my legs blood flowing
A client who reports inability to
dorsiflex his affected foot, difficulty with heel-toe gait, and
dragging of the foot along the ground while attempting to walk is
experiencing
symptoms of____
foot drop
Gustatory refers to the sense of
taste
Presbycusis is a type of age-
related ___ loss.
hearing
Turning an immobile client at least every _ hours helps to relieve pressure on specific areas and distribute the pressure evenly across the body, reducing the risk of pressure injury.
2 hr
___ is a medical term that refers to the involuntary discharge of urine, usually during sleep
enuresis
A sleep disorder characterized by walking or performing other
activities while
asleep is called
somnambulism
is a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early.
insomnia
Clients with migraines deal with different types of sensory
overload
____ reading, is a technique
used by people with hearing
impairments to understand spoken language by visually interpreting the
movements and shapes of the lips, tongue, and other facial expressions.
lip
The nurse is caring for a client who has difficulty walking after a traumatic accident. As a result of prolonged immobility, the nurse expects an ___ in calcium excretion
increase
Client reports that he finds himself falling asleep during the day, even in the middle of important meetings. What sleep disorder would the nurse suspect that the client is experiencing?
Hypersomnia
CPAP stands for Continuous ____ airway pressure, which is a medication device used to treat sleep apnea
positive
A nurse is planning for a home care plan for a client with cataract and partial hearing loss.Which of the following is a high-priority concern?
promoting safety
Which is an example of how exercise benefits our physiological and psychological functioning?
improve immune function
What is the appropriate nursing action when assessing a client's ability to perform a new exercise routine?
Identify any comorbidities or any existing medical conditions.
What should the nurse include in the
assessment considerations
for immobile clients?
Elimination capacity.
What is an appropriate initial exercise for a client with unstable angina?
brisk walking
Muscle ___ is a condition characterized by the loss of muscle mass and strength due to prolonged periods of inactivity or immobility.
atrophy
Which condition is the nurse trying to assess by having the client cross his arms in the chest towards the opposite shoulders and then palpating the spine while the client bends forward?
scoliosis
The nurse creates a new plan for a sedentary
60-year-old male
client that includes maintaining and increasing strength and
flexibility. As the nurse knows that low-impact exercises are
recommended, what are some examples of such exercises?
yoga and walking
In an _ range of motion exercise, the client independently moves joints through their full range of motion (isotonic exercise).
active
What is an indication that the nurse is maintaining correct body alignment?
Carrying equipment with a straight back and bent knees.
A neurological condition that results in the loss or impairment of language functions, including speaking, understanding, reading, and writing is called
aphasia
To ensure effective support for a client who has hearing difficulties
at home, the nurse should advise the client to obtain
phones with ____speakers.
amplified
Which indicates the impact of a good night's sleep?
Sleep promotes rejuvenation and tissue repair.
Keeping a sleep ___ 14 days
is a diagnostic tool that helps in
developing a treatment plan for clients experiencing narcolepsy.
diary
Proper body ___ refers to the way in which the body is positioned and moved during physical activity to avoid injuries and strain on the muscles and joints.
mechanics
Which client is contraindicated for heat therapy?
⁃ A client who broke his femur after a falling
A movement of the foot where the foot is pointed downwards is called plantar
flexion
Which nursing intervention is appropriate for an older adult who cannot sleep due to feeling cold.
Allow the client to wear insulated bed socks.
Used to cause mydriasis ( dilation or pupil) and cycloplegia ( Ciliary paralysis).
Anticholinergics
Alteration of middle ear, sounds and blocked before reaching the cochlea of the inner ear. Hears better in noisy environment, speaking softly, obstruction in ear Canal, TM with holes or scarring, Rinne test with AC</=BC, weber test materializes to affected ear.
Conductive hearing loss
Alteration of inner ear, auditory nerve, or hearing center of the brain. Tinnitus, dizziness, hears poorly in noisy environment, speaks loudly, no otoscopic findings, Rinne test AC>BC, weber test lateralizees to unaffected ear, acoustic neuroma ( benign tumor CN VII)
Sensorineural hearing loss
Combination of conductive and sensorineural
Mixed hearing loss