12: Altered Somatic and Special Sensory Function
First-order neurons
impulses from somatic receptors to the brain stem or spinal cord (transmit sensory information from the periphery to the central nervous system)
Which of these clients' statements would be most suggestive of retinal detachment?
"I feel like there's a shadow that's blocking my vision." Explanation: The primary symptom of retinal detachment consists of painless changes in vision. Commonly, flashing lights or sparks, followed by small floaters or spots in the field of vision, occur as the vitreous pulls away from the posterior pole of the eye. As detachment progresses, the person perceives a shadow or dark curtain progressing across the visual field. It is not associated with headache or bleeding.
Strabismus
"cross eyed" lack of coordinated extrinsic eye muscle function that prevents the eyes from lining up in the same direction
otosclerosis
(hardening of the bones of the middle ear resulting in a conductive hearing loss) -an autosomal-dominant condition -represents the most common cause of chronic, progressive, conductive hearing loss. Slow formation of spongy bone at the oval window immobilizes the footplate of the stapes, impairing the conduction of vibration
Which hearing test would be prescribed to help differentiate conductive from sensorineural hearing loss?
A Weber (tuning fork) test Explanation: A Weber test can be used to differentiate sensorineural hearing loss from conductive hearing loss. The test is performed using a tuning fork and is noninvasive. Audioscopes can be used to assess a person's ability to hear pure tones. ABRs determine the site of a lesion and the extent of damage.
When pupillary dilation partially compensates for the reduced size of the retinal image by increasing the light entering the pupil, this is a component of which eye adjustment?
Accommodation Explanation: Accommodation is the process whereby a clear image is maintained as gaze is shifted from far to near objects. During accommodation, pupillary dilation partially compensates for the reduced size of the retinal image by increasing the light entering the pupil. Accommodation requires convergence of the eyes, pupillary constriction, and thickening of the lens through contraction of the ciliary muscle, which is controlled mainly by the parasympathetic fibers of the oculomotor cranial nerve (CN III). A third component of accommodation involves reflex narrowing of the palpebral opening during near vision and widening during far vision.
An otherwise healthy client has been referred to a pain clinic because he is experiencing exquisite pain from the friction of his clothes on his torso. This client is likely to be diagnosed with which health problem?
Allodynia Explanation: Allodynia is pain that follows a non-noxious stimulus to apparently normal skin. Visceral pain is a deep, nonspecific pain that results from disruption of organs or deep tissues. Hypoalgesia is an abnormal decrease in pain sensitivity, whereas primary hyperalgesia describes pain sensitivity that occurs directly in damaged tissues.
What is ocular muscle imbalance resulting in "lazy eye" called?
Amblyopia Explanation: Ocular muscle imbalance resulting in "lazy eye" is known as amblyopia. Myopia is the error in refraction resulting from altered focus on an image in front of the retina due to lens thickness. If the anterior-posterior dimension of the eyeball is too short, the image is theoretically focused posterior to (behind) the retina. This is called hyperopia or farsightedness. The term presbyopia refers to a decrease in accommodation that occurs because of aging.
dermatome
Area of skin supplied by a single spinal nerve
A client reveals that, when in bed, changes in head position cause brief periods of vertigo, usually lasting less than 1 minute. Which condition is the client most likely experiencing?
Benign paroxysmal positional vertigo Explanation: Benign paroxysmal positional vertigo (BPPV) is characterized by brief periods of whirling or spinning, usually lasting less than 1 minute, that are precipitated by a change in head position. The most prominent symptom of BPPV is vertigo that occurs in bed when the person rolls into a lateral position.
Which clients will the nurse recognize are at an increased risk of thermal injury when using an external heating pad?Select all that apply.
Client who is an older adult. Client who has diabetes. Client who has peripheral neuropathy Client who has a spinal cord injury.
For which type of hearing loss should the nurse assess in a child who has had recurrent otitis media since birth?
Conductive loss Explanation: Hearing loss that is associated with recurrent otitis media is conductive loss.
Which characteristic differentiates open-angle glaucoma from angle-closure glaucoma?
Dysfunction of the aqueous humor drainage system Explanation: The chief pathologic feature in primary open-angle glaucoma is an abnormality of the trabecular meshwork that controls the flow of aqueous humor into the canal of Schlemm. In angle-closure glaucoma, the impaired outflow results from occlusion of the iridocorneal angle itself. Both carry strong risk of blindness and are evidenced by optic nerve cupping, and neither has an infectious etiology.
What is the result of depolarization of the hair cells inside the cochlea?
Impulse generation and transmission to the brain Explanation: Depolarization of the hair cells inside the cochlea results in impulse generation and transmission to the brain. The remaining answer choices do not represent the result of depolarization of the hair cells.
The nurse is teaching a client the purpose of using an external heating pad. What should the nurse include in the teaching plan?Select all that apply.
It promotes healing by accelerating the body's natural inflammatory response. It reduces the discomfort of muscle tension and muscle spasms It helps to relieve pain from arthritis and joint stiffness. It can be used to treat inflammation, chronic pain, and surgical wounds.
The nurse is conducting a health promotion class on the prevention of blindness and vision impairment. The nurse determines that participants understand the information when they identify which vision disorder as most likely to have an infectious etiology?
Keratitis Explanation: Cataracts, glaucoma, and macular degeneration are not caused by infectious organisms. However, keratitis may be caused by viruses, bacteria, fungi, and amebae.
A client's history documents the presence of the homonymous hemianopia. What assessment finding would the nurse anticipate this client to display?
Loss of the same side of the visual field in each eye Explanation: The loss of the same half-fields in the two eyes is called a homonymous loss, and the abnormality is called homonymous hemianopia.
Select the tactile receptors that are sensitive to the movement of very light objects over the surface of the skin.
Meissner corpuscles Explanation: Meissner corpuscles are particularly sensitive to the movement of very light objects over the surface of the skin and low-frequency vibration. Free nerve endings detect touch and pressure. Merkel disks allow for continuous determination of touch against the skin. Ruffini end-organs are involved in heavy and continuous touch and pressure.
Select the statement that best describes Meniere disease.
Meniere disease is a disorder of the inner ear due to distention of the endolymphatic compartment of the inner ear, causing hearing loss, vertigo, and tinnitus. Explanation: Meniere disease is a disorder of the inner ear due to distention of the endolymphatic compartment of the inner ear, causing a triad of hearing loss, vertigo, and tinnitus.
Allodynia
Pain due to a stimulus that does not normally provoke pain
Which visual deficit is a clinician justified in attributing to the normal aging process?
Presbyopia Explanation: The term presbyopia refers to a decrease in accommodation that occurs because of aging. Conjunctivitis, strabismus, and angle-closure glaucoma are considered abnormal and pathologic in clients of all ages.
The nurse is assessing a client's hearing and wants to determine if the client has hearing loss of certain frequencies. Which audiometry test will the nurse perform?
Pure-tone audiometry Explanation: Pure-tone audiometry involves recognition of faintest tones at selected pitches in the absence of background noise. Speech determination score and speech reception threshold are both audiometry tests; however, are not used to determine hearing loss at certain frequencies. The whisper test is not discussed as an audiometry test.
A client is experiencing chest pain that radiates to the left arm and neck. The nurse would interpret this pain as:
Referred Explanation: Referred pain is pain that is perceived at a site different from its point of origin but innervated by the same spinal segment. Visceral pain originates in the visceral organs and is one of the most common pains produced by disease. Cutaneous pain arises from superficial structures. Somatic pain originates in deep body structures.
A client expresses concern about feeling fullness in the ear. Which additional manifestation leads the health care provider to suspect Menière disease?
Rotary vertigo and tinnitus Explanation: Menière disease is characterized by fluctuating episodes of tinnitus, feelings of ear fullness, and violent rotary vertigo (room spinning) that often renders the person unable to sit or walk. Nausea and vomiting, hearing loss, and falls may accompany the disease, but these signs and symptoms are less definitive than frequent episodes of rotary vertigo accompanied by tinnitus.
A client with rheumatoid arthritis has taken high doses of aspirin for several years. Which type of hearing loss is this client at high-risk of developing due to ototoxicity?
Sensorineural hearing loss Explanation: Ototoxicity results in sensorineural hearing loss. Several drug classes have been identified as having ototoxic potential, including salicylates (e.g., aspirin).
The nurse is caring for an older adult client with a suspected diagnosis of presbycusis. Select the most likely manifestation.
Sensorineural hearing loss caused by natural aging Explanation: Presbycusis is a common report among older adults. It is manifested by the inability to hear what is being said in a conversation. Pressure may result from increased fluid, and buzzing or ringing may be a complication of medication.
A client has been diagnosed with sensorineural hearing loss. What should the care team assess to determine a plausible cause?
The client's recent medication use Explanation: Ototoxic responses to medications can result in sensorineural hearing loss. Cerumen accumulation can cause conductive hearing loss. The client's immunization status and the patency of Eustachian tubes are not related to the most common causes of sensorineural hearing loss.
The health care provider is assessing the functional integrity of all spinal nerves utilizing a pinpoint pressed against the skin. A normal response would be interpreted as:
The withdrawal reflex is activated. Explanation: Observation of a normal withdrawal reflex rules out peripheral nerve disease, disorders of the dorsal root and ganglion, disease of the myoneural junction, and severe muscle diseases. Having no response is abnormal and may identify neurologic damage. A verbal response is not a reflex response.
Which pain disorder is a manifestation of a disruption of cranial nerve function?
Trigeminal neuralgia Explanation: Trigeminal neuralgia is manifested by facial tics or spasms and characterized by paroxysmal attacks of stabbing pain that usually are limited to the unilateral sensory distribution of one or more branches of the trigeminal cranial nerve (CN V). Cranial nerve involvement is not implicated in postherpetic neuralgia, phantom limb pain, or TMJ syndrome.
A 2-year-old child who has had otitis media (OM) for 4 months and been treated with several courses of antibiotics now appears to have some hearing loss. The nurse anticipates that the most appropriate treatment for the child would be:
Tympanostomy tube insertion Explanation: Tympanostomy tubes should be the next course of action with the child having hearing loss and OM persisting for 4 months or longer. The parents should be taught to continue to monitor for signs of OM.
While assessing a client with suspected Menière disease, the nurse would expect which clinical manifestation?
Vertigo Explanation: Menière disease, which is caused by an overaccumulation of endolymph, is characterized by severe, disabling episodes of tinnitus, feelings of ear fullness, and violent rotary vertigo.
homonymous hemianopia
a condition in which a person sees only one side ― right or left ― of the visual world of each eye
Presbyopia
a condition of farsightedness associated with aging, results from the inability of the ciliary muscle and lens to accommodate for near vision -condition is easily corrected with bifocals
Although both vertigo and dizziness can result from peripheral or central vestibular disorders, vertigo is distinctly different because it causes:
an illusion of motion. Explanation: Vertigo or dizziness can result from peripheral or central vestibular disorders (proprioception) unrelated to hearing loss. Vertigo is a vestibular disorder in which a unique illusion of motion occurs. Persons with vertigo frequently describe it as a sensation of spinning or tumbling, a "to-and-fro" motion, or falling forward or backward. Light-headedness, faintness, and unsteadiness are different in that the person perceives weakness yet still has a sense of balance. Syncope (loss of consciousness) is not directly associated with the sensation of vertigo.
mastoiditis
an infection of the mastoid bone of the skull. The mastoid is located just behind the ear
Audioscopes
can be used to assess a person's ability to hear pure tones at 1000 to 2000 Hz (usual speech frequencies)
Acute otitis media (AOM)
characterized by otalgia (earache), fever, temporary conductive hearing loss, and excess middle ear fluid in combination with signs and symptoms of an acute or systemic infection -1st line: amoxicillin or Augmentin -Alternative if PCN allergy --> Cefdinir or cefuroxime, ceftriaxone
Otitis media with effusion (OME)
condition in which the tympanic membrane is intact and there is an accumulation of fluid in the middle ear without fever or other signs or symptoms of infection
The nurse is making a plan of care for a client in the initial stage of otosclerosis. Which assessment finding correlates to the early development of this diagnosis?
inability to hear whispering Explanation: The symptoms of otosclerosis involve an insidious hearing loss. Initially, the affected person is unable to hear a whisper or someone speaking at a distance. In the earliest stages, the person's own voice sounds unusually loud, and the sound of chewing becomes intensified. Because of bone conduction, most of these persons can hear fairly well on the telephone, which provides an amplified signal. Many are able to hear better in a noisy environment. The pressure of otosclerotic bone on inner ear structures or the vestibulocochlear nerve (cranial nerve VIII) may contribute to the development of tinnitus, sensorineural hearing loss, and vertigo.
esotropia
inward turning of the eye -medial deviation
The nurse is caring for a client experiencing phantom limb pain after amputation. The nurse applies which theory of pain to best help explain the client's pain?
neuromatrix Explanation: Because there is no physical stimulus present in phantom limb pain, theories that focus on nerve impulse transmission such as gate control, pattern, and specificity do not adequately explain this phenomenon. The neuromatrix theory of pain describes pain as a complex, multidimensional experience that can produce pain in the absence of a sensory trigger, making it the most helpful in explaining phantom pain.
Intensity theory of pain
pain occurs as a result of intense stimulation of any sensory modality in the absence of distinct pathways for low- and high-threshold stimuli ie: tactile stimulation that, as a single event, is not perceived as pain but when repeated a number of times achieves an intensity level that is perceived as painful
Meissner corpuscles
particularly sensitive to the movement of very light objects over the surface of the skin and low-frequency vibration
Third-order neurons
relay information from the thalamus to the cerebral cortex
specificity theory of pain
sensations of touch, warmth, cold, and pain involve distinct receptors and pathways unique to the specific sensation
Benign positional vertigo
sudden onset after rolling onto affected side, lasts less than a minute. no loss of hearing or tinnitus. sometimes there is nausea, vomiting, nystagmus
A client with a history of migraine headaches tells the physician that he or she usually experiences an aura before the onset of the headache. The client is most likely experiencing:
visual disturbances Explanation: Migraine aura is associated with visual symptoms, including flickering lights, spots, or loss of vision; sensory symptoms, including feeling of pins or needles, or numbness; and speech disturbances or other neurologic symptoms.
An older adult client is scheduled for outpatient cataract surgery. While taking a presurgery history, which statement by the client correlates to the manifestations of cataracts, thereby verifying the client has received information about the condition?
"I have blurred vision in both my eyes and my vision is distorted." Explanation: Age-related cataracts, which are the most common type, are characterized by increasingly blurred vision and visual distortion. Symptoms of conjunctivitis include a foreign body sensation, a scratching or burning sensation, itching, and photophobia or light sensitivity. Severe pain suggests corneal rather than conjunctival disease. A discharge, or exudate, may be present. It is usually watery when the conjunctivitis is caused by allergy, a foreign body, or viral infection and it is usually mucopurulent (mucus mixed with pus) in the presence of bacterial or fungal infection. Trauma that causes abrasions of the cornea can be extremely painful. Glaucoma is a chronic, pressure-induced degenerative neuropathy that produces changes in the optic nerve and visual field loss.
The nurse is working with a client who has been diagnosed with recurring migraine headaches. Which advice by the nurse is most appropriate?
"Many people find that maintaining regular eating and sleeping habits is beneficial." Explanation: Nonpharmacologic treatment includes the avoidance of migraine triggers, such as foods, that precipitate an attack. Many persons with migraines benefit from maintaining regular eating and sleeping habits. The client may need to change her lifestyle, but not to the extent of moving and changing jobs. Migraines are avoidable, most of the time, if individuals adhere to their diets and watch the triggers. Medication is very useful for most clients.
The nurse is assessing a client who has been diagnosed with esotropia. The nurse would expect the assessment findings to include:
Medial deviation Explanation: Disorders of eye movement are described according to the direction of movement. Esotropia refers to medial deviation, exotropia to lateral deviation, hypertropia to upward deviation, hypotropia to downward deviation, and cyclotropia to torsional deviation.
Which characteristic differentiates a migraine with aura from a migraine without aura?
Visual symptoms such as flickering lights precede the headache Explanation: An aura is visual (flickering lights, spots, or loss of vision), sensory (feeling of pins and needles, or numbness), and/or speech disturbance that precedes a migraine. Nonpharmacologic treatments may be used with varying success in both types of migraine, and nausea and vomiting may precede or accompany each. Changes in mood and affect are not central to an aura.
Sensorineural hearing loss
hearing loss also called nerve deafness -often permanent, resulting from disease, trauma, or genetic inheritance of a defect in the cochlea nerve cells
pure tone conduction (Weber tuning fork)
hearing test can be used to evaluate the inner ear, independent of middle and outer ear function -sensorineural -A small vibrator is placed on either the forehead or the mastoid bone, directly stimulating the auditory nerve
The nurse is teaching a client about various methods of pain control. Which information will the nurse include when teaching the client about applying heat for pain control?
"Heat promotes more blood flow to the area to improve oxygen supply." Explanation: Heat dilates blood vessels and increases local blood flow, which reduces the level of nociceptive stimulation by reducing local ischemia. Although it can help reduce swelling, this is not done through vasoconstriction. Prostaglandin release promotes the inflammatory response and the sensation of pain, so this would not be a desired effect and is not an effect of heat application. Heat has been thought to increase endogenous opioids, which can help reduce the experience of pain. Although heat can modulate pain, it does not block the brain's ability to interpret pain signals.
An older adult client has been diagnosed with macular degeneration. Which statement by the client best demonstrates an accurate understanding of the new diagnosis?
"I suppose that this may be one of the things that happens when you get older." Explanation: Although some risk factors have been identified for macular degeneration, most diagnoses are attributed to increased age. The pathogenesis does not involve infection or hypertension, and a corneal transplant is not a recognized treatment modality.
The nurse is caring for a client with acute musculoskeletal pain. Which statement will the nurse include when teaching the client about the use of heat as a method of pain control? (Select all that apply.)
-"Heat releases endogenous opioids." -"Heat reduces local ischemia." Explanation: Heat increases local circulation, reducing local ischemia. Additionally, heat releases endogenous opioids. Application of cold constricts the blood vessels, decreasing swelling. Additionally, cold reduces afferent activity. Acupuncture mediates endorphin release.
A client asks if pain threshold and pain tolerance are the same. The best response by the health care provider would be:
"Pain threshold is the point at which a stimulus is perceived as painful." Explanation: Pain threshold is closely associated with the point at which a nociceptive stimulus is perceived as painful. Pain tolerance relates more to the total pain experience; it is defined as the maximum intensity or duration of pain that a person is willing to endure before the he or she wants something done about the pain. Psychological, familial, cultural, and environmental factors significantly influence the amount of pain a person is willing to tolerate. The threshold for pain is fairly uniform from one person to another, whereas pain tolerance is extremely variable.
The nurse offers a client recovering from knee surgery a prescribed opioid analgesic. The client states, "I don't find the pain that severe. I think acetaminophen will be fine." How should the nurse respond?
"This is fine as long as your pain tolerance allows you to participate in the prescribed postoperative exercises." Explanation: The nurse should accept that pain is a subjective experience and that the client's perception of the level of pain is influenced by many individual factors, including the client's pain threshold and tolerance. If the client's pain tolerance allows for participation in postoperative recovery activities, there is no need to use opioid analgesia despite what may be typical for other clients who have undergone the same procedure. While opioids mimic naturally occurring modulating chemicals to reduce the experience of pain, opioids do not speed the recovery better than other forms of analgesia that the client deems as adequate based on individual tolerance.
A diabetic client has developed diabetic neuropathy and is prescribed pharmacologic intervention. The medication most likely to be prescribed would be an:
Antiseizure Explanation: Antiseizure medications that suppress spontaneous neuronal firing are particularly useful in the management of pain that occurs after nerve injury (neuropathic pain), including diabetic neuropathy and chronic regional pain syndrome. The other categories would be prescribed for anxiety, allergic reaction, or infections.
The nurse is explaining the role of aqueous humor in the development of glaucoma to a client who has just been diagnosed with the condition. How should the nurse describe the role of aqueous humor in the pathogenesis of glaucoma?
Aqueous humor is continually produced and drained to maintain the appropriate pressure. In glaucoma, the normal drainage is impeded and the increased pressure can damage the optic nerve. Explanation: Normal pressure of the aqueous humor requires a balanced rate of aqueous humor production and secretion. Glaucoma usually results from lesions of the eye that mechanically obstruct aqueous outflow. There is never accelerate drainage in glaucoma and inflammation does not result in overproduction of the aqueous humor.
A client who has cut a finger drops the knife in pain. Which component of this pain signal was transmitted by third-order neurons?
Between the thalamus and the cerebral cortex Explanation: First-order neurons transmit sensory information from the periphery to the central nervous system. -Second-order neurons communicate with various reflex networks and sensory pathways in the spinal cord and travel directly to the thalamus. Third-order neurons relay information from the thalamus to the cerebral cortex. This typology does not apply to motor neurons.
A client is brought to the emergency department after a bicycle accident. He landed on his back and has been unable to move since the accident, despite the absence of obvious head injuries. The physician will focus assessment of the client's neurologic status by testing which aspects of his body?
Each dermatome Explanation: A dermatome is an area of skin that is supplied by a single pair of dorsal roots and would represent each area of the body. Testing each spinal nerve is not necessary, his dermis is a layer of skin, and the pupillary reflex can be generally used for assessing brain damage, not motor damage.
To maintain fixation on stable objects during head rotation, the eyes slowly drift in the opposite direction and then jump rapidly back toward the direction of rotation. This process is known by what term?
Nystagmus Explanation: The term nystagmus is used to describe the vestibulo-ocular reflexes that occur in response to ongoing head rotation. The vestibulo-ocular reflexes produce slow compensatory conjugate eye rotations that occur in the direction precisely opposite to ongoing head rotation and provide for continuous, ongoing reflex stabilization. This pattern of slow-fast-slow movements is called nystagmus. Spontaneous nystagmus that occurs without head movement or visual stimuli is always pathologic. Disorders of ear vestibular function are characterized by vertigo, in which an illusion of motion occurs. Eyelid movements are unrelated to visual fixation on an object. Conjugate gaze is looking at an object with both eyes, without movements of the head.
With aging, progressive inelasticity and thickening of the lens causes which accommodation disorder?
Presbyopia Explanation: Presbyopia describes the changes in vision that occur because of aging. No loss of lens fibers occurs, but instead, additional fibers are added to the outermost portion and the lens thickens, the fibers become less elastic, the range of focus or accommodation is diminished, and reading glasses become necessary for near vision. Hyperopia or farsightedness occurs when the anterior-posterior dimension of the eyeball is too short and the image is focused posterior to (behind) the retina. Myopia or nearsightedness occurs when the anterior-posterior dimension of the eyeball is too long and the image is focused anterior to the retina. Astigmatism is non-uniform curvature of the refractive surface, usually caused by a defect in the cornea. Cataracts form with normal aging when the nucleus and the cortex of the lens enlarge as new fibers are formed in the cortical zones; old fibers become more compressed and dehydrated. During the early stages of cataract formation, a yellow pigment and vacuoles accumulate in the lens fibers.
The nurse is teaching a client about the treatment of open-angle glaucoma. The most appropriate information for the nurse to give the client would be:
administration of topical beta-adrenergic antagonists to lower the pressure. Explanation: The elevation in intraocular pressure in persons with open-angle glaucoma is usually treated pharmacologically or, in cases where pharmacologic treatment fails, by increasing aqueous outflow through a surgically created pathway. Medication is generally administered topically.
Second-order neurons
impulses from the brain stem and spinal cord to the thalamus
Topical β-adrenergic antagonists
are thought to lower intraocular pressure by decreasing aqueous humor production by constricting the vessels supplying the ciliary body -usually the drugs of first choice for open-angle glaucoma
Conductive hearing loss
failure in the vibration of the eardrum and/or movement of the ossicles -localized to the outer or middle ear, and it may be temporary or permanent
A 55-year-old client has been diagnosed with acute angle-closure glaucoma. The client's ophthalmologist is recommending immediate and aggressive drug treatment because the:
increase in intraocular pressure will cause degradation of the optic nerve. Explanation: Glaucoma causes an elevation in intraocular pressure. If left untreated, the pressure may increase sufficiently to cause ischemic and compressive degeneration of the optic nerve, leading to progressive blindness. The lens is not affected by pressure changes. Clouding of the lens is a cataract.
pattern theory of pain
perception of pain is derived from a specific pattern of neuronal impulse generation based on the type of stimulus and intensity, specifically the timing and location of impulse generation ie: light, superficial skin pressure would generate low-frequency receptor firing and the perceived sensation of light touch
otoacoustic emission (OAE)
tests used to evaluate outer hair cell function
During a routine 2-month checkup at the pediatric clinic, a mother expresses concern that her son looks "cross-eyed." She asks if she needs to put patches over his good eye. Assessment reveals full eye movement, and the child uses each eye independently. The health care provider explains that the best treatment for the infant's eye problem is:
to prepare for some surgery to correct this problem early in life in order to correct the eye muscle disorder. Explanation: The disorder may be nonaccommodative, accommodative, or a combination of the two. Infantile esotropia is the most common cause of nonaccommodative strabismus. It occurs in the first 6 months of life, with large-angle deviations, in otherwise developmentally and neurologically normal infants. Eye movements are full, and the child often uses each eye independently to alter fixation (cross-fixation). Infantile esotropia is usually treated surgically by weakening the medial rectus muscle on each eye while the infant is under general anesthesia. Recurrences are common with infantile esotropia, and multiple surgeries are often required.
A 38-year-old client who has begun to develop hearing loss is being evaluated by the nurse practitioner. The client tells the nurse that hearing improves when she is on the telephone and that chewing sounds very loud. What does the nurse practitioner suspect?
Otosclerosis Explanation: Otosclerosis involves the reabsorption of bone and replacement with new, sclerotic bone around the stapes and oval window, which slowly impedes hearing. The typical presentation is around 20 to 40 years of age. People with otosclerosis often experience an increase in the sound of chewing and can often hear on the telephone better than in person, due to the bone conduction of sound.
A client reports occasional ringing in the ears that worsens toward the end of the day. The most important question for the nurse to ask would be:
"What prescription medication and over-the-counter medication do you take?" Explanation: Medications and stimulants, such as aspirin, caffeine, and nicotine, can cause tinnitus. The client should be questioned to determine if this is a potential cause. Impacted cerumen is a benign cause of tinnitus, which resolves after the earwax is removed. Respiratory infections may cause fluid in the ears and decreased hearing.
The nurse is caring for an older adult client who reports a recent decline in hearing acuity and suspects "wax buildup." Which action will the nurse take first?
Assess the client to ensure the tympanic membrane is intact. Explanation: If the ear canal is obstructed with cerumen (ear wax) accumulation, irrigation with warm water may be done. First, the client must be assessed to ensure the tympanic membrane is intact. If it is not, fluid can enter the inner ear and cause complications. The nurse would not refer the client to an audiologist as the first step and does not prepare to irrigate the ear until an assessment has indicated it is safe to do so.
A client presents to the clinic complaining, "I have something in my eye." When questioned, the client admits to a scratching and burning sensation and light sensitivity. The health care provider suspects the client has developed:
Conjunctivitis Explanation: Conjunctivitis causes bilateral tearing, itching, burning, foreign body sensation, and morning eyelash crusting and eye redness. The primary symptom of retinal detachment is painless changes in vision. Commonly, flashing lights or sparks, followed by small floaters or spots in the field of vision, are early symptoms. Attacks of glaucoma (increased intraocular pressure) are manifested by ocular pain, excruciating headache, blurred or iridescent vision, and corneal edema with hazy cornea, dilated (mydriasis), and fixed pupil; with repeated or prolonged attacks, the eye becomes reddened. With corneal edema, the cornea appears dull, uneven, and hazy; visual acuity decreases; and iridescent vision (i.e., rainbows around lights) occurs.
What pain theory proposes that pain receptors share pathways with other sensory modalities and that different activity patterns of the same neurons can be used to signal painful or nonpainful stimuli?
Pattern Explanation: A group of pain theories known as the pattern theory proposes that receptors share pathways with other sensory modalities, and different activity patterns of the same neurons can be used to signal painful or nonpainful stimuli. The specificity theory regards pain as a separate sensory modality evoked by the activity of specific receptors that transmit information to forebrain pain centers, where pain is experienced. Gate control theory postulated the presence of neural gating mechanisms at the segmental spinal cord level to account for interactions between pain and other sensory modalities. The neuromatrix theory proposes that the brain contains a widely distributed neural network.
The nurse is caring for a client with visual impairment who states recent difficulty seeing clearly at night. Which condition does the nurse suspect the client may suffer from?
Vitamin A deficiency Explanation: Opsin (a protein) and retinene (a vitamin A derivative) combine to form rhodopsin, which breaks down when in contact with light, stimulating a nerve impulse. Even low levels of light promote the breakdown of rhodopsin, allowing night vision. Vitamin A deficiency leads to impaired night vision. The remaining answer choices do not lead to impaired night vision.
Which stimulus would be used to elicit the withdrawal reflex when testing response to nociceptive stimuli?
pressure from a sharp object Explanation: Of the stimuli listed, only pressure from a sharp object is sufficient to predictably produce a withdrawal reflex. The stimulus must be sufficient to produce a signal via the pain pathway and elicit a predictable response in the subject. Mild stimuli such as a weak electrical current or contact with objects close to body temperature will not be sufficient.
gate control theory of pain
stimulation of the large type A beta and alpha inhibitory fibers "close the gate" at the substantia gelatinosa, preventing crossover and inhibiting pain impulse conduction along type A delta and type C fibers, diminishing pain perception -meaning: Stimulation of small pain fibers promotes "opening the gate," activating neural transmission and perception of pain
Auditory brain stem-evoked responses (ABRs)
uses electrodes and high-gain amplifiers to produce a record of brain wave activity elicited during repeated acoustic stimulations of either or both ears. It involves subjecting the ear to loud clicks and using a computer to analyze nerve impulses as they are processed in the midbrain
The nurse is caring for a group of clients with visual impairment. Which clients does the nurse recognize as being at greatest risk for developing glaucoma? (Select all that apply.)
-African American male -Female with diabetes mellitus -Male with a history of eye trauma -Older adult with long-term use of corticosteroids Explanation: Risk factors for the development of glaucoma includes age, black race, diabetes, eye trauma, and long-term use of steroids. Long-term use of NSAIDs is not associated with an increased risk for the development of glaucoma.
The nurse is performing an eye assessment on a client who presents with a red eye. The nurse determines that the redness is related to bacterial conjunctivitis based on which additional symptom(s)?
Tearing, itching, and burning Explanation: Conjunctivitis causes bilateral tearing, itching, burning, foreign body sensation, and morning eyelash crusting and eye redness. Hyperacute conjunctivitis causes conjunctival redness and edema (chemosis), lid swelling and tenderness, and swollen preauricular lymph nodes. Attacks of glaucoma (increased intraocular pressure) are manifested by ocular pain, excruciating headache, blurred or iridescent vision, and corneal edema with hazy cornea, dilated (mydriasis), and fixed pupil; with repeated or prolonged attacks, the eye becomes reddened.
A 2-year-old child has been diagnosed with uncomplicated acute otitis media by a nurse practitioner. When explaining the plan of care, which description is most appropriate?
"Let's keep a close eye on his condition for a couple of days before starting antibiotics." Explanation: Observation without antimicrobial agents is an option in a child over 6 months of age with uncomplicated AOM. These approaches involve waiting for 24 hours to 72 hours (greater than 6 months of age) to see if symptoms improve before institution of antibiotic therapy. Antiviral medications and decongestants are ineffective and rinsing of the ears is not curative.
A middle-aged client whose father experienced progressive vision loss from macular degeneration (MD) asks the nurse if there is anything that can reduce the risk of developing MD. How should the nurse respond?
"You can reduce your risk by preventing high blood pressure and maintaining a healthy weight." Explanation: Nonmodifiable risk factors for the development of MD include being older than 60 years of age and having a family history. The nurse should teach the client about controlling modifiable risk factors, including smoking, having hypertension, and being overweight. There is no way to predict if the client would develop the wet or dry form of MD and this will not alter the prevention approach. There are no preventive treatments for dry MD and injections used for wet MD do not prevent this form of the disease. Intraocular injections of vascular endothelial growth factor are used after the diagnosis of wet MD is made in order to reduce the formation of new blood vessels and slow the disease progression.
A new mother brings her infant to the clinic reporting that the child is not sleeping or eating much. Upon assessment, the health care provider notes that the infant's ear canal is reddened with a bulging tympanic membrane. Which other data collected would lead to the diagnosis of acute otitis media (AOM)? Select all that apply.
-"Yes, he has been pulling at his ear." -"He's been very irritable and fussy the past couple of days." Explanation: AOM is characterized by an acute onset of otalgia (ear pain), fever, and hearing loss. Younger children often have nonspecific signs and symptoms that manifest as ear tugging, irritability, nighttime awakening, and poor feeding. Key diagnostic criteria include ear pain that interferes with activity or sleep, tympanic membrane erythema (redness), and middle ear effusion. A child with otitis media with effusion (OME) may develop delayed speech and language skills.
The nurse is assessing an older adult client who presented to the emergency department due to acute onset unilateral eye pain, headache, nausea, and vision changes. The nurse takes which immediate actions? Select all that apply.
-Assess pupil size bilaterally. -Notify the ophthalmologist on call. Explanation: Due to the client's presentation of eye pain, headache, nausea, and vision changes, the nurse should prioritize assessing for evidence of acute angle-closure glaucoma. Because this condition may be induced by increased pupil dilation, the nurse assesses the client's pupil size. The nurse may also assess if the client sees "rainbows" around lights as additional evidence. Because damage to the optic nerve can develop rapidly and surgical management is often indicated in acute angle-closure glaucoma, the nurse notifies the appropriate health care provider to avoid delays in diagnosis and treatment. The nurse will not patch the eye as this would promote pupil dilation, which prevents the outflow of aqueous humor and would increase intraocular pressure. The nurse may ask the client about areas of vision loss but would not take the time to perform a Snellen chart assessment, which determines distance visual acuity. Macular degeneration does not result in eye pain, headache, or nausea, so this is not a priority assessment.
Which intervention would be considered a nonpharmacologic method of pain control? Select all that apply.
-Distraction by knitting -Guided imagery -Biofeedback Explanation: A number of nonpharmacologic methods of pain control are used in pain management. These include cognitive behavioral interventions (e.g., relaxation, distraction, imagery, and biofeedback), physical agents (e.g., heat and cold), electroanalgesia (transcutaneous electrical nerve stimulation [TENS]), and acupuncture. Even though acetaminophen is an over-the-counter pain medication, it is still a pharmacologic intervention.
The nurse is caring for a child diagnosed with acute otitis media (AOM). What are risk factors associated with AOM? Select all that apply.
-Family history of recurrent AOM -Premature birth -Presence of siblings in the household -Cleft lip and palate Explanation: Risk factors for AOM include premature birth, male gender, ethnicity, family history of recurrent OM, attendance at day care, and presence of siblings in the household. AOM is more frequent in children with orofacial abnormalities such as cleft lip and palate.
As part of the community health department, a nurse is educating a group of diabetic clients about prevention of blindness. Which topics should be covered during this class? Select all that apply.
-Importance of yearly eye exams -Tight control of blood glucose levels -Keep BP below 130/85 (American Heart Association Guidelines) Explanation: Current guidelines recommend that persons with diabetes have yearly eye examinations. Preventing diabetic retinopathy from developing or progressing is considered the best approach to preserving vision. Growing evidence suggests that careful control of blood glucose levels in persons with diabetes mellitus may slow the onset and progression of retinopathy. There also is a need for intensive management of hypertension and hyperlipidemia, both of which have been shown to increase the risk of diabetic retinopathy in persons with diabetes.
Parents with a profoundly deaf child ask, "How can you test such a young infant for hearing loss?" The health care provider will likely explain which testing procedures? Select all that apply.
-Tuning fork -Audioscope -Auditory brain stem-evoked responses (ABRs) Explanation: Tuning forks are used to differentiate conductive and sensorineural hearing loss. Audioscopes can be used to assess a person's ability to hear pure tones at 1000 to 2000 Hz (usual speech frequencies). The ABR uses electrodes and high-gain amplifiers to produce a record of brain wave activity elicited during repeated acoustic stimulations of either or both ears. It involves subjecting the ear to loud clicks and using a computer to analyze nerve impulses as they are processed in the midbrain. Imaging studies such as computed tomography (CT) scans and magnetic resonance imaging (MRI) can be done to determine the site of a lesion (if tumor is suspected) and the extent of damage.
The nurse is teaching the caregivers of a toddler being treated for amblyopia. Which information will the nurse include? Select all that apply.
-You will have to be attentive due to an increased risk for physical injury." -"Your toddler may not be able to notice objects placed on one side." -"This condition often results from lack of eye muscle coordination." Explanation: Amblyopia ("lazy eye") may be caused by strabismus, a lack of eye muscle function resulting in uncoordinated eye movements. Because this prevents the eyes from lining up in the same direction, the brain suppresses one of the images, resulting in visual impairment on one side. This could result in the child not noticing objects placed on this side and increase the risk for physical injury. Because there can be permanent loss of vision in one eye due to amblyopia, the nurse does not tell the caregivers the child requires no intervention. Myopia is nearsightedness. Although refraction errors may be present in amblyopia, the visual impairment is limited to one eye.
The nurse is implementing distraction strategies for a client who is experiencing pain. Which distraction strategy(ies) will the nurse to implement? Select all that apply.
-engaging in conversation about the client's hobbies -providing the client with earbuds for listening to music -encouraging the client to watch a movie -offering a deck of cards to the client and visitor Explanation: Distraction helps clients divert their attention away from pain and onto other activities. Distraction may provide sensory shielding whereby attention to other stimuli decreases the perception of pain. Any activity that requires some degree of sensory attention such as listening to music, watching a movie, playing cards, or engaging in conversation can work as distraction. Acetaminophen is an analgesic and not distraction. Although some clients may request quiet when coping with pain, this is not a form of distraction.
The nurse is caring for a toddler diagnosed with mastoiditis as a complication from otitis media. The caregivers refused antibiotics to treat the toddler's original ear infection. In order to promote adherence to therapy, the nurse teaches the caregivers about which potential complications of not adequately treating the mastoiditis? Select all that apply.
-meningitis -brain abscess -facial palsy Explanation: Mastoiditis is a bacterial infection of the air cells of the mastoid bone. The nurse should emphasize complications of mastoiditis that are potentially fatal or can result in permanent disability such as meningitis, brain abscess, and facial palsy. Otosclerosis is a congenital cause of progressive hearing loss and is not a complication of mastoiditis. External otitis (acute otitis externa or swimmer's ear) is inflammation of the outer ear which could be present along with otitis media but is not considered a complication of mastoiditis.
An adult client presents with new onset of involuntary oscillations of both eyes. For which possible causes of this finding will the nurse assess the client? Select all that apply.
-recent alcohol use -evidence of head injury -evidence of acute stroke -diagnosis of multiple sclerosis Explanation: Involuntary oscillations of the eye are known as nystagmus. Although this can be caused by a congenital condition, the fact that this client is an adult and the onset is new does not support congenital nystagmus. Instead, the nurse assesses for possible acute causes such as alcohol or drug intoxication, head injury, or stroke. Having the underlying condition of multiple sclerosis is also associated with developing nystagmus, which can be transient given the pattern of exacerbations and remissions of this chronic neurologic disorder.
When lecturing about heart attacks (myocardial infarctions), the instructor will emphasize the client may present with: Select all that apply.
-substernal chest pain. -neck pain. -pain that radiates to the left arm. Explanation: Referred pain is perceived at a site different from the location of its point of origin but innervated by the same spinal segment. The sites of referred pain are determined embryologically with the development of visceral and somatic structures that share the same site for entry of sensory information into the central nervous system (CNS) and then move to more distant locations. Pain that originates in the abdominal or thoracic viscera is diffuse and poorly localized and is often perceived at a site far removed from the affected area. For example, the pain associated with myocardial infarction commonly is referred to the left arm, neck, and chest, which may delay diagnosis and treatment of a potentially life-threatening condition.
Place the process of sensation of taste in the correct order.
1. Substances are dissolved in the saliva 2. Molecules released penetrate the taste buds 3. Molecules released bind to taste receptors 4. Transmission of the taste signal 5. Impulse travels to the gustatory cortex Explanation: Substances must be dissolved in saliva to stimulate a taste response. Once dissolved, molecules released from food and drink by chewing, drinking or digesting food penetrate the taste buds, bind to the taste receptor on the gustatory hairs of the taste cell, and transmit the taste signal via action potentials along associated dendrites. Impulses then travel to the gustatory cortex.
Processes of Nociception
1. Transduction -of noxious stimuli into a nerve impulse and depolarization of the nerve stimulates the conduction of the sensory impulse 2. Transmission -of nerve impulses from tissues to the CNS -Responses of the brain resulting from the transmission of impulses must be delivered back to the original site of stimulation 3. Modulation -of the pain occurs during transmission of the impulse 4. Perception -Modulation of the pain occurs during transmission of the impulse
A parent of a child with otitis media with effusion (OME) asks, "How is this different from typical acute otitis media (AOM)?" Which response by the nurse correctly identifies the main difference?
Excess middle ear fluid Explanation: Otitis media with effusion (OME) is a condition in which the tympanic membrane is intact and there is an accumulation of fluid in the middle ear without fever or other signs or symptoms of infection. Acute otitis media (AOM) is characterized by otalgia (earache), fever, temporary conductive hearing loss, and excess middle ear fluid in combination with signs and symptoms of an acute or systemic infection.
A 60-year-old client's long history of poorly controlled hypertension has culminated in a diagnosis of retinal detachment. What type of retinal detachment is this client most likely to have experienced?
Exudative retinal detachment Explanation: Exudative (or serous) retinal detachment results from the accumulation of serous or hemorrhagic fluid in the subretinal space due to severe hypertension, inflammation, or neoplastic effusions. Rhegmatogenous retinal detachment is a full-thickness break ("rhegma") in the sensory retina, with the passage of liquefied vitreous through the break into the subretinal space. Persons with high grades of myopia or nearsightedness may have abnormalities in the peripheral retina that predispose to sudden detachment. In moderate to severe myopia, the anteroposterior length of the eye is increased, and the retina tends to be thinner and more prone to formation of a hole or tear. As a result, there is greater vitreoretinal traction, and posterior vitreous detachment may occur at a younger age than in persons without myopia. Traction retinal detachment occurs with mechanical forces on the retina, usually mediated by fibrotic tissue, resulting from previous hemorrhage (e.g., from diabetic retinopathy), injury, infection, or inflammation. Intraocular surgery such as cataract extraction may produce traction on the peripheral retina that causes eventual detachment months or even years after surgery.
A 5-month-old infant is being treated for acute otitis media (AOM) for the second time in the past 10 weeks. Which action should the nurse recommend to prevent future recurrences?
Limiting the infant's exposure to large group settings Explanation: Ways to reduce the risk of developing AOM include minimal exposure to group settings. MMR and hepatitis vaccines are irrelevant to the etiology of AOM. Ear rinsing is not recommended.
The nurse is caring for a premature neonate who requires supplemental oxygen therapy. Which action does the nurse prioritize to best prevent complications?
Titrate oxygen therapy based on oxygen saturation levels. Explanation: The nurse can best prevent complications related to over- or under-oxygenation by titrating treatment based on the neonate's oxygen saturation levels. High concentrations of oxygen increase the risk of retinopathy of prematurity (ROP). The risk for ROP must be balanced with the risk for complications related to hypoxia. The nurse ensures oxygen does not exceed what is necessary. Assessing lung sounds can only inform if there are changes to airflow, such as the presence of fluid, but will not inform how much oxygen is required. Oxygen delivery should be based on the neonate's physiologic response and not limited to a certain number of liters, as this level may be inadequate to achieve minimally acceptable oxygen saturation levels. Indirect oxygen delivery will not reduce the risk of ROP if the concentrations of oxygen are in excess of what the neonate requires.
While playing outside in the snow a young child did not keep gloves on. In the emergency department, the child reported painful fingertips. The nurse knows this painful sensation is a result of which transmission of proprioceptive somatosensory information?
Type C dorsal root ganglion neurons Explanation: All somatosensory information from the limbs and trunk shares a common class of sensory neurons called dorsal root ganglion neurons. The unmyelinated type C fibers have the smallest diameter and the slowest rate of conduction. They convey warm-hot sensation and mechanical and chemical as well as heat- and cold-induced pain sensation. Somatosensory information from the face and cranial structures, however, is transmitted by trigeminal sensory neurons, which function in the same manner as the dorsal root ganglion neurons. The second-order neurons communicate with various reflex networks and sensory pathways in the spinal cord and contain the ascending pathways that travel to the thalamus. In contrast to the dorsal column-medial lemniscal pathway, the anterolateral pathway transmits sensory signals such as pain, thermal sensations, crude touch, and pressure that do not require highly discrete localization of the signal source or fine discrimination of intensity.
A client develops fever, headache, and burning/itching in the periorbital area. After a few days, a vesicular rash appears around the eyelid margins. The health care provider will likely prescribe:
antiviral medication for herpes zoster ophthalmicus. Explanation: Herpes zoster ophthalmicus usually presents with malaise, fever, headache, and burning and itching of the periorbital area. These symptoms commonly precede the ocular eruption by a day or two. The rash, which is initially vesicular, becomes pustular and then develops crusts. Treatment includes the use of oral and intravenous antiviral drugs. Initiation of treatment within the first 72 hours after the appearance of the rash reduces the incidence of ocular complications but not the postherpetic neuralgia. Chlamydial conjunctivitis is commonly spread by contact with genital secretions. It is treated with antimicrobial medications. Causes of ulcerative keratitis include infectious agents, exposure to trauma, and use of extended-wear contact lenses. The first manifestations of recurrent herpes keratitis are irritation, photophobia, and tearing. A history of fever blisters or other herpetic infection is often noted. Allergic conjunctivitis encompasses a spectrum of conjunctival conditions usually characterized by itching. Allergic conjunctivitis also has been successfully treated with topical mast cell stabilizers, histamine type 1 (H1) receptor antagonists, and topical nonsteroidal anti-inflammatory drugs.
The nurse is caring for a client who reports having a mildly painful, itchy ear canal with no other associated symptoms. For which condition will the nurse assess the client based on the presenting symptoms?
external otitis (acute otitis externa or swimmer's ear) Explanation: The symptoms best align with external otitis (acute otitis externa) which is inflammation of the external ear also known as swimmer's ear. Manifestations include itching, redness, tenderness, and narrowing of ear canal due to swollen tissues that may or may not lead to mild hearing loss. The nurse would expect more severe pain and hearing loss and additional symptoms such as fever or enlarged lymph nodes if the client had otitis media. Barotrauma results from sudden changes in atmospheric pressure resulting in middle ear pressure being out of balance with atmospheric pressure. The client would describe pressure and popping if barotrauma were present rather than itching. Mastoiditis is a bacterial infection of the air cells of the mastoid bone that often occurs as a complication of otitis media. If this were present, the nurse would expect to see evidence of inflammation and bacteria infection such as fever.
A client has been diagnosed with open-angle glaucoma during a routine eye exam. The client has been prescribed a topical β-adrenergic antagonist. Client teaching about how this drug works should include which of the following statements? β-adrenergic antagonists:
lower intraocular pressure by decreasing aqueous humor production. Explanation: Topical β-adrenergic antagonists, which are thought to lower intraocular pressure by decreasing aqueous humor production, are usually the drugs of first choice. The α-adrenergic agonists cause an early decrease in production of aqueous humor by constricting the vessels supplying the ciliary body. -Carbonic anhydrase inhibitors reduce the secretion of aqueous humor. Cholinergic drugs exert their effects by increasing the effects of acetylcholine (a postganglionic neurotransmitter in the parasympathetic nervous system) and increase aqueous outflow through contraction of the ciliary muscle and pupillary constriction.
