Sensory Function Case Study with Rationale
2022
During the initial interview, the nurse inspects the external anatomy of the eye. The
eye is a sensory organ of vision, and it is well protected by a bony orbital cavit
...
Sensory Function Case Study with Rationale
2022
During the initial interview, the nurse inspects the external anatomy of the eye. The
eye is a sensory organ of vision, and it is well protected by a bony orbital cavity and
surrounded with a cushion of fat. The RN notes tat the cornea looks cloudy and an
arcus senilis is seen around the cornea.
Q. Which action should the nurse take first? - A. Assess whether the cornea looks
thickened and raised and document the finding.
(Rationale) As the lipid accumulates, the cornea may look thickened and raised. The
assessment finding should be documented in the electronic medical record
During the assessment of Frank's hearing, the nurse performs a series of tests,
including Frank's ability to hear whispered and conversational tones.
Q. How will the nurse assess for the presence of tinnitus? - A. Ask the client if he
ever hears ringing in his ears.
(Rationale) Tinnitus is the presence of ringing in the ears, which is often associated
with hearing loss.
Frank seems nervous and asks for a glass of water. After taking a drink, he attempts
to set the glass down, but places the glass on the edge of the counter, causing it to
crash to the floor.
Q. To follow up this situation, which assessment will provide the most useful data? -
A. Visual field and depth perception.
(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.
Frank's visual acuity is measured using a Snellen chart. The reading obtained is
20/80 in the right eye and 20/200 in the left eye.
Q. How should the nurse explain these findings to Frank? - A. "You are very nearsighted, especially in your left eye."
(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).
As the interview continues, the nurse notes that Frank is very pleasant and nods his
head in agreement with all of the nurse's statements, but that he often does not
respond to simple requests during the assessment.
Q. Which nursing diagnosis is best supported by the data available? - A. Disturbed
sensory alteration (auditory).
(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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