Sensory perception

A client has been receiving digoxin. The client call the clinic and complains of "yellow vision." Which response would the nurse provide?

"The medication may need to be discontinued. Come to the clinic this afternoon."

Which condition results in visual distortion?

Astigmatism

A client with hemiparesis voices a reluctance to use a cane. Which rationale would the nurse use to explain the cane's purpose to the client?

Maintain balance to improve stability

An older client with Alzheimer type dementia, consistently sleeps in a semi-Fowler position in bed. Which area of the client's body would the nurse consider a high risk for developing a pressure injury? Sacrum Scapulae Ischial spine Great trochanter

Sacrum The sacrum in the center of the greatest body mass; an elevated torso exerts pressure toward this area.

The nurse is performing an assessment and notes that the client has exophthalmos and complains of double vision. These assessment findings are consistent with which condition?

Hyperthyroidism

Which definition of photphobia is accurate? Double vision Foreign body sensation Persistent abnormal intolerance to light Gradual or sudden inability to see clearly

Persistent abnormal intolerance to light

During an annual physical assessment, a client reports not being able to smell coffee and most food. Which cranial nerve function would the nurse assess?

CN I

After a discectomy and fusion surgery, the client wants to attempt walking with assistance for the first time. Upon rising to a standing position, the client reports feeling faint and light headed. Which action would the assisting nurse have the client do upon hearing the client's concern?

Have the client sit on the edge of the bed so the nurse can hold the client upright. Sitting maintains alignment of the back and allows the nurses to support the client until orthostatic hypotension subside.

Which structure is a component of the auditory ossicles? Malleus Vestibule Tympanic membrane External acoustic meatus

Malleus The malleus along with the incus and stapes constitutes the auditory occicles. The vestibule is present in the inner ear and is an organ of balance. The tympanic membrane (eardrum) is a part of the middle ear. The external acoustic meatus is a component of the external ear.

Which medication would the nurse identify as a potential cause for the formation of abnormally small eyes in the newborn if used during pregnancy?

Nitrofurantoin

which visual system assessment technique provides a magnified view of the retina and optic nerve?

Ophthalmoscopy

Which is the middle layer of the eyeball? Sclera Retina Uveal tract Transparent cornea

Uveal tract The uveal tract (which consists of the iris, choroid, and ciliary body) is considered the middle layer of the eyeball.

A 50 year old client has difficulty communicating because of expressive aphasia after a CVA. When the nurse inquired about the client's feelings, the spouse responded. Which communication strategy would the nurse use to address this behavior?

Acknowledge the spouse, but look at the client for a response.

Damage to which cranial nerve may lead to decreased olfactory acuity?

Cranial nerve I

Which function of limbic system is accurate? Influence emotional behavior Regulate autonomic functions Facilitate autonomic movements Relay sensory and motor inputs for cerebrum

Influence emotional behavior Located lateral to the hypothalamus, the limbic system influences emotional behavior and basic drives such as feeding and sexual behaviors. The regulation of the endocrine and autonomic functions is the function of the hypothalamus. The control and facilitation of learned and automatic movements is the function of the basal ganglia. The thalamus relays sensory and motor input to and from the cerebrum.

A 2 year old toddler has hearing loss caused by recurrent otitis media. Which would the nurse anticipate the practitioner will recommend?

Myringotomy Myringotomy is a surgical opening into the eardrum to permit drainage of the accumulation of fluid.

Which condition is associated with involuntary and rapid twitching of the eyeball? Ptosis Anisocoria Nystagmus Enophthalmos

Nystagmus Nystagmus is associated with involuntary and rapid twitching of the eyeball. Ptosis is characterized by drooping of eyelids. Anisocoria is characterized by a normally noticeable difference in the size of the pupils and is a normal finding in 5% of the population. Enophthalmos is characterized by the sunken appearance of the eye.

After a cerbrovascular accident (CVA, also known as "brain attack"), a client is unable to differentiate between heat or cold and sharp or dull sensory stimulation. The nurse would conclude that CVA affected which lobe of the brain?

Parietal Sensory impulses from temperature, touch, pain trabel via the spinothalamic pathway to the thalamus and then to the postcentral gyrus of the parietal lob, the somatosensory area.

A recently hospitalized client with MS voices a concern about generalized weakness and fluctuating physical status. Which nursing intervention is the priority for this client?

Space activities throughout the day.

Which action elicits the brachioradialis reflex? Striking the triceps tendon above the elbow Striking the radius 3-5 cm above the wrist Striking the patellar tendon just below the patella Striking the achilles tendon when the client's leg is flexed

Striking the radius 3-5 cm above the wrist. The brachialradialis reflex can be elicited by striking the radius 3-5 cm above the wrist while the client's are is relaxed. Striking the triceps tendon above the elbow elicits the triceps reflex. Striking the patellar tendon just below the patella elicits the patellar reflex. Striking the achilles tendon elicits the achilles tendon reflex when the client's leg is flexed.

An adult client with low functioning down syndrome (trisomy 21) appears in the emergency department via ambulance after an accident. Which assessment method would be the best instrument to use when determining the client's level of pain?

Using the Wong-Baker FACES Pain Rating Scale

Which structure lies inside and parallel to the sclera? Lens Choroid Conjunctiva Ciliary processes

Choroid The choroid is a highly vascular structure that nourishes the ciliary body, the iris, and the outermost portion of the retina. It lies parallel to the sclera. The lens is located behind the iris. The conjunctiva covers the inner surface of the eyelids and also extends over the sclera. The ciliary processes lie behind the peripheral part of the iris.

Which medication may cause photophobia as an adverse effect?

Clomiphene Clomiphene is a fertility medication that may cause photphobia.

Which type of rehabilitation is an essential component to a client's recovery from Guillain-Barre Syndrome? Physical therapy Speech exercises Fitting with a vertebral brace Follow up on cataract progression

Physical Therapy Rehabilitation needs for a client with Guillain-Barre syndrome focuses on physical therapy and exercise for lower extremities because of muscle weakness and discomfort.

Which key feature is associated with a stage 2 pressure ulcer? Presence of nonintact skin Development of sinus tracts Damage of the subcutaneous tissue Appearance of a reddened area over a bony prominence

Presence of nonintact skin Sinus tracts may develop during stage 4. The subcutaneous tissue becomes damaged or necrotic during stage 3. A reddened area over a bony surface occurs in stage 1.