Sensory Perception PrepU

Menopause marks the end of a reproductive capacity. Which of the following is a common complaint that may be due to a cystocele?

A cystocele can cause dyspareunia and incontinence. See Table 32-2 in the text for a complete list of both structural and functional age-related changes.

The nurse is performing a neurological assessment. What will this assessment include?

A neurological assessment evaluates sensation and motion. Assessing plantar flexion of the toes would be included in a neurological assessment. Capillary refill, palpation of pulses, and inspecting for edema would be included in a vascular assessment.

A nurse is working on a neurological unit with a nursing student who asks the difference between primary and secondary headaches. The nurse's correct response will include which of the following statements?

A secondary headache is a symptom associated with an organic cause, such as a brain tumor or an aneurysm. A primary headache is one for which no organic cause can be identified. These types include migraine, tension, and cluster headaches. Secondary headaches can be located in all areas of the head.

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?

A transient ischemic attack (TIA) is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. Symptoms may disappear within 1 hour; some continue for as long as 1 day. When the symptoms terminate, the client resumes his or her presymptomatic state. The symptoms do not describe a left- or right-sided stroke or a cerebral aneurysm.

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:

Acute angle-closure glaucoma is characterized by the symptoms listed, as well as by being rapidly progressive and accompanied by pain.

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do?

Administer atropine to control the side effects of edrophonium. Atropine should be available to control the side effects of edrophonium, which include bradycardia, sweating, and cramping.

The nurse is performing the Rinne test on a client with a sensorineural hearing loss. Which of the following would the nurse expect?

Air-conducted sound heard longer than bone-conducted sound With the Rinne test, a person with sensorineural hearing loss hears air-conducted sound longer than bone-conducted sound. A person with normal hearing would report that the air-conducted sound is louder than the bone-conducted sound. Hearing the sound better in the affected ear would be reported by a client with conductive hearing loss during the Weber test. Describing the sound as centered in the middle of the head would be reported by a person with normal hearing during the Weber test.

A client has experienced an ischemic stroke that has damaged the temporal (lateral and superior portions) lobe. Which of the following deficits would the nurse expect during assessment of this client?

Auditory agnosia Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to motor neurons may cause hemiparesis, hemiplegia, and a change in reflexes.

The nurse is administering an ophthalmic ointment to a patient with conjunctivitis. What disadvantage of the application of an ointment does the nurse explain to the patient?

Blurred vision results after application. Ophthalmic ointments have extended retention time in the conjunctival sac and provide a higher concentration than eye drops. The major disadvantage of ointments is the blurred vision that results after application. In general, eyelids and eyelid margins are best treated with ointments.

During assessment of a patient with a hearing loss, the nurse notes a defect in the tympanic membrane. The nurse documents this disturbance as a loss known as:

Conductive A defect in the tympanic membrane or interruption of the ossicular chain disrupts normal air conduction, which results in a conductive hearing loss.

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called:

Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. The stapes must move freely for sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, preventing sound transmission. In a functional hearing loss, no organic lesion is found. Fluctuating hearing loss is a form of sensorineural hearing loss that varies over time. Sensorineural hearing loss affects the inner ear and involves the cochlea and eighth cranial nerve.

A client is color blind. The nurse understands that this client has a problem with:

Cones provide daylight color vision, and their stimulation is interpreted as color. If one or more types of cones are absent or defective, color blindness occurs. Rods are sensitive to low levels of illumination but can't discriminate color. The lens is responsible for focusing images. Aqueous humor is a clear watery fluid and isn't involved with color perception.

Which of the following is the main refracting surface of the eye?

Cornea

The nurse is establishing a visual test using the Snellen chart for a client experiencing visual changes. At which distance should the nurse instruct the client to stand?

A 20-foot distance

An acoustic neuroma is a benign tumor of which cranial nerve?

An acoustic neuroma is a benign tumor of the eighth cranial nerve, the cranial nerve most responsible for hearing and balance.

Which nursing intervention should be included during the assessment of a client with an eye disorder?

Check the extraocular muscles by instructing the client to keep his or her head still when following an object.

Which is an accurate clinical manifestation of a retinal detachment?

Clients can complain of bright flashing lights as a clinical manifestation of retinal detachment. Clients with retinal detachment do not complain of pain. Seeing colored halos around lights is specific to glaucoma. Chemosis does not usually occur with retinal detachment.

Which symptoms may a client with Ménière disease report before an attack?

Clients with Ménière disease experience symptoms of headache and a full feeling in the ear before an attack. Nystagmus is an episodic symptom that occurs during an attack, and, at times, the client is symptom free. Ménière disease does not cause low blood pressure or photosensitivity.

A client has been referred to an ophthalmologist for suspected macular degeneration. The nurse knows to prepare what test for the physician to give the client?

Clients with macular problems are tested with an Amsler grid. It is made up of a geometric grid of identical squares with a central fixation point. The examiner instructs the client to stare at the central fixation spot on the grid and report if they see any distortion of the squares. Clients with macular problems may say some of the squares are faded or wavy. An Ishihara polychromatic plate, visual field, or slit lamp test will not diagnose macular degeneration.

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect?

Constricted pupils are a parasympathetic effect; dilated pupils are a sympathetic effect.

The nurse is performing an assessment of cranial nerve function and asks the patient to cover one nostril at a time to see if the patient can smell coffee, alcohol, and mint. The patient is unable to smell any of the odors. The nurse is aware that the patient has a dysfunction of which cranial nerve?

Cranial nerve (CN) I is the olfactory nerve, which allows the sense of smell. Testing of CN I is done by having the patient identify familiar odors with eyes closed, testing each nostril separately. An inability to smell an odor is a significant finding, indicating dysfunction of this nerve.

A client has an exacerbation of multiple sclerosis. The physician orders dantrolene (Dantrium), 25 mg P.O. daily. Which assessment finding indicates the medication is effective?

Dantrolene reduces muscle spasticity.

The nurse is assessing a client newly diagnosed with myasthenia gravis. Which of the following signs would the nurse most likely observe?

Diplopia and ptosis

Which of the following is an example of a topical anesthetic?

EMLA cream is a topical anesthetic. Bacitracin, Silvadene, and Garamycin are topical antibiotics.

A client is undergoing testing to confirm a diagnosis of myasthenia gravis. The nurse explains that a diagnosis is made if muscle function improves after the client receives an IV injection of a medication. What is the medication the nurse tells the client he'll receive during this test?

Edrophonium (Tensilon) The most useful and reliable diagnostic test for myasthenia gravis is the edrophonium (Tensilon) test. Within 30 to 60 seconds after injection of edrophonium, most clients with myasthenia gravis will demonstrate a marked improvement in muscle tone that lasts about 4 to 5 minutes. Cyclosporine, an immunosuppressant, is used to treat myasthenia gravis, not to diagnose it. Immunoglobulin G is used during acute relapses of the disorder. Azathioprine is an immunosuppressant that's sometimes used to control myasthenia gravis symptoms.

A nurse is providing care to a client who has had a stroke. Which symptoms are consistent with left-sided stroke?

Expressive aphasia, defects in the right visual fields, problems with abstract thinking are symptoms of left hemispheric stroke. Impulsive behavior, poor judgment, deficits in left visual fields are symptoms of right hemispheric stroke. Cautious behavior, deficits in left visual fields, misjudgment of distances are symptoms inconsistent with each other as some indicate left and others indicate right hemispheric stroke. Problems with abstract thinking, impairment of short-term memory, poor judgment are symptoms inconsistent with each other as some indicate left and others indicate right hemispheric stroke.

Which terms refers to blindness in the right or left half of the visual field in both eyes?

Homonymous hemianopsia occurs with occipital lobe tumors. Scotoma refers to a defect in vision in a specific area in one or both eyes. Diplopia refers to double vision or the awareness of two images of the same object occurring in one or both eyes. Nystagmus refers to rhythmic, involuntary movements or oscillations of the eyes.

What kind of otitis media is a pathogen-free fluid behind the tympanic membrane, resulting from irritation associated with respiratory allergies and enlarged adenoids?

Serous otitis media, a collection of pathogen-free fluid behind the tympanic membrane, results from irritation associated with respiratory allergies and enlarged adenoids. The other options are distractors for this question. Purulent otitis media usually results from the spread of microorganisms from the eustachian tube to the middle ear during upper respiratory infections.

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

When assessing the pressure of the anterior chamber of the eye, a nurse normally expects to find a pressure of:

10 to 20 mm Hg.

A client with progressive hearing loss is diagnosed with a malignant tumor of the right external ear. For which additional alteration in physical status will the nurse assess the client?

Facial nerve paralysis Malignant tumors may occur in the external ear. Most common are basal cell carcinomas on the pinna and squamous cell carcinomas in the ear canal. If untreated, squamous cell carcinoma may spread through the temporal bone, causing facial nerve paralysis and hearing loss. Since the client is already experiencing a change in hearing, the facial nerve needs to be assessed. The client does not need to be assessed for a frontal headache, cervical node edema, or parotid gland hypertrophy.

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?

Guillain-Barre syndrome typically begins with muscle weakness and diminished reflexes of the lower extremities (hyporeflexia). Fever, skin rash, cough, and ptosis are not signs/symptoms associated with Guillain-Barre.

A client with an inflammatory ophthalmic disorder has been receiving repeated courses of a corticosteroid ointment, one-half inch in the lower conjunctival sac four times a day as directed. The client reports a headache and blurred vision. The nurse suspects that these symptoms represent:

Headache and blurred vision are symptoms of increased IOP, such as from glaucoma. Ophthalmic corticosteroids may trigger an episode of acute glaucoma in susceptible clients. Although the effects of some drugs may diminish with continued use, this doesn't happen with ophthalmic corticosteroids. Incorrect ointment application doesn't cause headache or blurred vision.

On the third day after a partial thyroidectomy, a client exhibits muscle twitching and hyperirritability of the nervous system. When questioned, the client reports numbness and tingling of the mouth and fingertips. Suspecting a life-threatening electrolyte disturbance, the nurse notifies the surgeon immediately. Which electrolyte disturbance most commonly follows thyroid surgery?

Hypocalcemia may follow thyroid surgery if the parathyroid glands were removed accidentally. Signs and symptoms of hypocalcemia may be delayed for up to 7 days after surgery. Thyroid surgery doesn't directly cause serum sodium, potassium, or magnesium abnormalities. Hyponatremia may occur if the client inadvertently received too much fluid; however, this can happen to any surgical client receiving I.V. fluid therapy, not just one recovering from thyroid surgery. Hyperkalemia and hypermagnesemia usually are associated with reduced renal excretion of potassium and magnesium, not thyroid surgery.

Which test uses a tuning fork shifted between two positions to assess hearing?

In the Rinne test, the examiner shifts the stem of a vibrating tuning fork between two positions to test air conduction of sound and bone conduction of sound. The whisper test involves covering the untested ear and whispering from a distance of 1 or 2 feet from the unoccluded ear, then determining the ability of the client to repeat what was whispered. The watch tick test relies on the ability of the client to perceive the high-pitched sound made by a watch held at the client's auricle. The Weber test uses bone conduction to test lateralization of sound.

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead The Weber test is performed by striking the tuning fork and placing its stem in the midline of the client's skull or in the center of the forehead. In the Rinne test, the tuning fork is struck and placed on the mastoid process behind the ear. The tuning fork is not placed near the external meatus of each ear or under the bridge of the nose.

Postoperative nursing assessment for a patient who has had a mastoidectomy should include observing for facial paralysis, which might indicate damage to which cranial nerve?

Injury to the seventh cranial nerve, also known as the facial nerve, is a complication of a mastoidectomy, although rare. Hearing loss of less than 30 dB is a more common complication.

Which of the following is considered a central nervous system (CNS) disorder?

Multiple sclerosis is an immune-mediated, progressive demyelinating disease of the CNS. Guillain-Barré, myasthenia gravis, and Bell's palsy are peripheral nervous system disorders.

What type of medication would the nurse use in combination with mydriatics to dilate the patient's pupil?

Mydriasis, or pupil dilation, is the main objective of the administration of mydriatics and cycloplegics (Table 63-3). These two types of medications function differently and are used in combination to achieve the maximal dilation that is needed during surgery and fundus examinations to give the ophthalmologist a better view of the internal eye structures.

The nurse recognizes the following as marker(s) of medication effectiveness in glaucoma control except:

Opacity of the lens The main markers of the efficacy of the medication in glaucoma control are lowering of the intraocular pressure to the target pressure, stable appearance of the optic nerve head, and the visual field. Opacity of the lens relates to cataract formation.

A patient is diagnosed with a spinal cord tumor and has had a course of radiation and chemotherapy. Two months after the completion of the radiation, the patient complains of severe pain in the back. What is pain an indicator of in a patient with a spinal cord tumor?

Pain is the hallmark of spinal metastasis. Patients with sensory root involvement may suffer excruciating pain, which requires effective pain management.

A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:

Presbyopia is a refractive change that occurs with age. The lens of the eye loses accommodative power. Opacity in the lens indicates a cataract.

The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential?

Raise your hand when you no longer hear sound.

The nurse is instructing the client with dried cerumen blocking the ear canal on potential methods to reduce symptoms. Which at-home methods of cerumen removal are discouraged?

Removing the cerumen by means of a cotton tip applicator The nurse is an important resource person to consult when a client has an issue with the ear structure or hearing. The nurse is correct to discourage placing anything down the ear canal that could push the cerumen deeper toward or puncture the tympanic membrane. The other options are appropriate to soften and lubricate the cerumen or to irrigate the cerumen from the ear.

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

Tetany may result if the parathyroid glands are excised or damaged during thyroid surgery. Hemorrhage is a potential complication after thyroid surgery but is characterized by tachycardia, hypotension, frequent swallowing, feelings of fullness at the incision site, choking, and bleeding. Thyroid storm is another term for severe hyperthyroidism — not a complication of thyroidectomy. Laryngeal nerve damage may occur postoperatively, but its signs include a hoarse voice and, possibly, acute airway obstruction.

Prior to an eye exam for possible macular degeneration, the nurse completes a history of symptoms. The nurse is aware that a diagnostic sign of age-related dry macular degeneration is:

The appearance of tiny, yellow spots in the field of vision.

Which part of the retina is responsible for central vision?

The macula is the area of the retina responsible for central vision. The optic disk is the point of entrance of the optic nerve into the retina. The sclera helps maintain the shape of the eyeball and protects the intraocular contents from trauma. The fundus is the largest chamber of the eye and contains the vitreous humor.

Which nerve is being assessed when the nurses asks the client to dorsiflex the ankle and extend the toes?

The motor function of the peroneal nerve is assessed by asking the client to dorsiflex the ankle and to extend the toes, while pricking the skin between the great toe and center toe assesses sensory function. The radial nerve is assessed by asking the client to stretch out the thumb, then the wrist, and then the fingers at the metacarpal joints. The median nerve is assessed by asking the client to touch the thumb to the little finger. Asking the client to spread all fingers allows the nurse to assess motor function affected by ulnar innervation.

There are 12 pairs of cranial nerves. Only three are sensory. Select the cranial nerve that is affected with decreased visual fields.

The three sensory cranial nerves are I, II and VIII. Cranial nerve II (optic) is affected with decreased visual fields and acuity.

The upper eyelid normally covers the uppermost portion of the iris and is innervated by which cranial nerve?

The upper lid is innervated by the oculomotor nerve (CN III). Cranial nerve I is the olfactory nerve, cranial nerve II is the optic nerve, and cranial nerve IV is the trochlear nerve.

A patient is being tested for a gag reflex. When the nurse places the tongue blade to the back of the throat, there is no response elicited. What dysfunction does the nurse determine the patient has?

The vagus nerve (cranial nerve X) controls the gag reflex and is tested by depressing the posterior tongue with a tongue blade. An absent gag reflex is a significant finding, indicating dysfunction of this nerve.

Which statement describes benign paroxysmal positional vertigo (BPPV)?

The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired. BPPV is a brief period of incapacitating vertigo that occurs when the position of the client's head is changed with respect to gravity. The vertigo is usually accompanied by nausea and vomiting; however, generally, hearing impairment does not occur. The onset of BPPV is sudden and followed by a predisposition to positional vertigo, usually for hours to weeks but occasionally months or years. BPPV is thought to be caused by the disruption of debris within the semicircular canal. This debris forms from small crystals of calcium carbonate from the inner ear structure, the utricle. BPPV is frequently stimulated by head trauma, infection, or other events.

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?

This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.

A patient having an acute stroke with no other significant medical disorders has a blood glucose level of 420 mg/dL. What significance does the hyperglycemia have for this patient?

This is significant for poor neurologic outcomes. Hyperglycemia has been associated with poor neurologic outcomes in acute stroke and should be treated if the blood glucose is above 140 mg/dL (Summers et al., 2009).

What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss It is important that nurses are knowledgeable about the ototoxic effects of certain medications such as salicylates, loop diuretics, quinidine, quinine, and aminoglycosides. Signs and symptoms of ototoxicity include tinnitus and sensorineural hearing loss. Hypotension, reduced urinary output, and impaired facial movement are not signs of ototoxicity.

A client is suspected of having amyotrophic lateral sclerosis (ALS). To help confirm this disorder, the nurse prepares the client for various diagnostic tests. The nurse expects the physician to order:

To help confirm ALS, the physician typically orders EMG, which detects abnormal electrical activity of the involved muscles. To help establish the diagnosis of ALS, EMG must show widespread anterior horn cell dysfunction with fibrillations, positive waves, fasciculations, and chronic changes in the potentials of neurogenic motor units in multiple nerve root distribution in at least three limbs and the paraspinal muscles. Normal sensory responses must accompany these findings. Doppler scanning, Doppler ultrasonography, and quantitative spectral phonoangiography are used to detect vascular disorders, not muscular or neuromuscular abnormalities.

During assessment for cranial nerve functions, the client closes the eyes and begins to fall to one side. Which cranial nerve alteration causes this response?

cranial nerve VIII Nerve receptors for balance are found both in the vestibule and semicircular canals. They transmit information about motion through the vestibular nerve, which joins with the cochlear nerve to form the eighth cranial nerve (formally called the auditory or acoustic nerve).

A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for:

hypoxia Lower brain stem dysfunction alters bulbar functions, such as breathing, talking, swallowing, and coughing. Therefore, the nurse should monitor the client closely for hypoxia. Temperature control, vision, and gait aren't lower brain stem functions.