The nurse has assessed the assigned group of clients. Which client would the nurse identify as being at the greatest risk for alterations in sensory perception?

  • a client in a halo vest following an automobile accident
  • a child with severe autism who is having a tonsillectomy
  • a teenager who broke her leg during cheerleader practice
  • a schoolteacher who was hospitalized for shortness of breath
Number 2 is correct.
A child with severe autism who is having a tonsillectomy is at greatest risk for alterations in sensory perception. Clients with severe autism experience altered thought processes. Adding an unfamiliar environment (the hospital) with pain from a surgical procedure compounds the risk of altered sensory perception. The client in the halo vest may have pain and restricted mobility, but he does not have as great a risk for altered perception as the child with severe autism. A teenager who broke her leg during cheerleader practice is more likely to have a large social group and be less isolated. A schoolteacher is more likely to work in a stimulating environment and have many social contacts. Risk factors for altered perception include emotional disorders, a non-stimulating environment, acute illness, limited mobility, pain, decreased cognitive ability, and impaired hearing or vision.