Sensory Perception

The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, she would a. notify the physician. b. document the finding in the records. c. recheck the reflex after several hours. d. monitor the eye movements and pupil reactions closely.

ANS: A The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.

The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? a. I will take my child to the audiologist because he doesnt seem to hear me except when I look directly at him. b. Both of my children have the same eye medication, which is a real bonus, because I need only buy one bottle. c. Making my child wear ear plugs when she goes to a rock concert may save her hearing! d. I see now why when my child has a cold, he complains about everything tasting blah!

ANS: B Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.

. During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patients wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for a. tympanoplasty. b. irrigation of the ear. c. pure tone test. d. otoscopic exam by a specialist.

ANS: B The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.

An 80-year-old patient has a hearing deficit which he states is getting worse; his hearing aid needs to be replaced. He states he attends church but cannot understand the sermon anymore. He hates to go out to events because his hearing aid makes everything noisy. He notes nothing is the same. During the assessment he asks the nurse to repeat the question frequently. Nursing diagnoses would include which of the following? (Select all that apply.) a. Altered growth and development b. Social isolation c. Chronic confusion d. Activity intolerance e. Hopelessness f. Spiritual distress

ANS: B, E, F His lack of hearing has interfered with his social activities, including his church. There is no support for inability to be active physically, nor does he show signs of confusion. Because the loss is recent, growth and development were not affected.

Mr. K, an 80-year-old patient, is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident in when the daughter says which of the following? a. I will make sure that Dad always wears warm socks. b. Dad needs to wear his glasses so he can delay the onset of macular degeneration. c. I will ask the home health aide to carefully inspect Dads feet every day when she helps him bathe. d. We will give him only warm foods, so that he doesnt burn his mouth.

ANS: C Diabetes increases risk of peripheral neuropathy, and it is hard to inspect ones own feet. Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.

The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. To provide recreational activities during the rehabilitation phase, the nurse should a. place the television to the left or right of patients visual field. b. encourage the patient to learn braille. c. suggest use of talking books. d. provide headphones for listening to music.

ANS: C Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.

Mr. Smith is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. The nurses best response would be which of the following? a. Your wife should increase the spices in your food, as the pneumonia changes your sense of smell. b. Notify your doctor immediately, because this is a concerning reaction to the medication. c. You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection. d. You should see an improvement in the next week or so. Call if this continues.

ANS: D Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.

The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? a. This will help us to identify your babys risk for ear infections the first year of life. b. Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother. c. Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child. d. Imitation of sounds is the first step in language development, and it is important to identify alterations early.

ANS: D Newborn screening of hearing does not identify risk of infection but only of sensory responses. The babys response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.

Mrs. J, a 57-year-old woman, walks into the emergency department with complaints of not feeling well. Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that Mrs. J has an open wound on the bottom of her foot, but the patient states she is not aware of this. The nurse interprets this response as a. normal in the older adult. b. a need for the patient to be evaluated for cognitive impairment. c. a side effect of anti-hypertensive medication. d. pathologic impairment of sensory responses.

ANS: D Though at 57 she is borderline for older, this degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely Ms. J has diabetes, which is causing decreased sensation. The not feeling well is secondary to a change in blood sugar secondary to the wound response.

A patient has completed a full course of antibiotics for acute otitis media. Which statement by the patient would lead the nurse to believe medication therapy was effective? a) "I no longer have dizziness". b) "I no longer have ear pain". c) "I no longer have nausea or vomiting". d) "I no longer have impaired hearing".

B is correct: "I no longer have ear pain"

A patient is diagnosed with glaucoma and started on Timolol. The nurse should assess for which possible complication to this medication? a) Anxiety b) Edema c) Hypertension d) Bradycardia

D is correct: bradycardia

Which action(s) is appropriate to safely bathe an older adult client? Select all that apply. a. Provide the client a long-handled shower brush or attachment if experiencing limited mobility. b. Use vigorous rubbing motions when drying the skin to increase circulation. c. Pour scented bath oils into the tub to improve dryness of the skin and decrease odors. d. Carefully monitor water temperature. e. Use a tub/shower seat if balance problems are present.

Use a tub/shower seat if balance problems are present. Carefully monitor water temperature. Provide the client a long-handled shower brush or attachment if experiencing limited mobility.

The nurse is providing postsurgical care for a 4-year-old boy following hernia repair. Before surgery, the nurse taught the child to use the poker chip tool to rate his pain. When assessing the child's postsurgical pain, the boy refuses to touch the chips and clings to his mother. How should the nurse respond? a. Give the mother the FACES pain rating scale to use with her son. b. Substitute the word-graphic rating scale for the poker chips. c. Show the child once more how to use the chips. d. Select the visual analog scale as the best one to use.

a is correct: give the mother the faces pain rating scale to use with her son

A woman who gave birth to a healthy newborn 2 months ago comes to the clinic and reports discomfort during sexual intercourse. Which suggestion by the nurse would be most appropriate? a. "You might try using a water-soluble lubricant to ease the discomfort." b. "This is entirely normal, and many women go through it. It just takes time." c. "It takes a while to get your body back to its normal function after having a baby." d. "Try doing Kegel exercises to get your pelvic muscles back in shape."

a is correct: you might try using a water soluble lubricant to ease the discomfort

what might cause vision problems within younger children?

accidental blunt trauma and chemical burns caused by household cleaners

iris

allows light to enter eye

A client has just been diagnosed with early glaucoma. During a teaching session, the nurse should: a. assess the client's visual acuity. b. demonstrate eyedrop instillation. c. provide instructions on eye patching. d. teach about intraocular lens cleaning.

b is correct: demonstrate eyedrop instillation

Which statement by the client indicates further teaching about epidural anesthesia is necessary? a. "A needle will deliver the anesthetic into the area around my spinal cord." b. "I will become unconscious." c. "I will lose the ability to move my legs." d. "I will be able to hear the surgeon during the surgery."

b is correct: i will become unconscious

The nurse is performing a neurologic assessment and requests that the patient stand with eyes open and then closed for 20 seconds to assess balance. What type of test is the nurse performing? a. Rinne test b. Romberg test c. Watch-tick test d. Weber test

b is correct: romberg

A patient comes to the clinic with a suspected eye infection. The nurse recognizes that the patient most likely has conjunctivitis, as evidenced by what symptom? a. Elevated IOP b. Blurred vision c. A mucopurulent ocular discharge d. Severe pain

c is correct: A mucopurulent ocular discharge

cochlea

connected to hearing ability

vestibular system

control balance

blindness

corrected visual acuity of 20/200 in better seeing eye

A male client has experienced a forceful hit to the testes. The nurse expects that the sensory nerves that transmit pain impulses are associated with which nervous system? a. Enteric nervous system b. Circulatory nervous system c. Endocrine nervous system d. Autonomic nervous system

d is correct: autonomic nervous sytem

The Apgar score is based on which 5 parameters? a. heart rate, breaths per minute, irritability, tone, and color b. heart rate, breaths per minute, irritability, reflexes, and color c. heart rate, respiratory effort, temperature, tone, and color d. heart rate, muscle tone, reflex irritability, respiratory effort, and color

d is correct: heart rate, muscle tone, reflex irritability, respiratory effort, and color

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report: a. a recent driving accident while changing lanes. b. frequent episodes of double vision. c. headaches, nausea, and redness of the eyes. d. light flashes and floaters in front of the eye.

d is the correct answer: light flashes and floaters in front of the eye

sensorineural hearing loss

disruption in afferent nerves necessary to transmit impulses

conductive hearing loss

disruption in transmission of sound or vibration in the outer canal and middle ear structure

eustachian tube

function is to equalize air pressure on both sides of ear drum

retina

transforms light impulses into electrical impulses that transmit to optic nerve

poor vison

visual acuity of less then 20/40 in better seeing eye