ch 30

A patient diagnosed with macular degeneration asks the nurse to explain his condition. Which statement by the nurse best describes macular degeneration? a) "The portion of your eye called the macula, which is responsible for central vision, is damaged." b) "Your lens became cloudy, causing your blurred vision. This cloudiness will increase over time." c) "The pressure in the anterior cavity of your eye became elevated, shifting the position of your lens." d) "There's an irregular curvature of your cornea, causing your blurred vision."

ANS: A Macular damage (degeneration) causes diminished central vision. Cataracts are caused by a cloudy lens and result in blurred vision. Glaucoma is pressure in the anterior cavity of the eye, which shifts the lens position. Astigmatism is irregular curvature of the cornea, resulting in blurred vision.

A patient tells the nurse that since taking a medication he has suffered from excessively dry mouth. Which of the following assessments would be needed to plan interventions for that symptom? a) Asking the patient whether foods taste different now b) Checking the patient's sense of smell c) Having the patient stand to check for balance d) Assessing for a history of seizures

ANS: A Many medications cause xerostomia (dry mouth), and xerostomia is the most common cause of impaired taste. Impaired sense of smell also affects the sense of taste; however, there is no reason to assume impaired smell in this patient. Balance is related to the inner ear and to kinesthetic sense, not to taste and xerostomia. Xerostomia would be related to seizures only if a patient experienced dry mouth as an aura; this would be unusual. Even if this were the case, the information would allow the nurse to plan care for seizures, but not for the symptom of dry mouth.

Which assessment finding is considered an age-related change? a) Presbycusis b) Hyperopia c) Increased sensitivity to touch d) Increased sensitivity to taste

ANS: A Presbycusis, the loss of high-frequency tones, is an age-related change. Hyperopia is the ability to see distant objects well; it is not an age-related change. The ability to perceive touch and taste diminishes with age; it does not increase.

Which step should the nurse take first when performing otic irrigation in an adult? a) Warm the irrigation solution to room temperature. b) Position the patient so she is sitting with her head tilted away from the affected ear. c) Straighten the ear canal by pulling up and back on the pinna. d) Place the tip of the nozzle into the entrance of the ear canal.

ANS: A The nurse should warm the irrigation solution to room temperature first. Next, the nurse should assist the patient into a sitting position, with the head tilted away from the affected ear; straighten the ear canal by pulling up and back on the pinna; place the tip of the nozzle into the entrance of the ear canal; and direct the stream of irrigating solution gently along the top of the ear canal toward the back of the patient's head. Then continue irrigating until the canal is clean.

Which structure within the brain is responsible for consciousness and alertness? a) Reticular activating system b) Cerebellum c) Thalamus d) Hypothalamus

ANS: A The reticular activating system, located in the brainstem, controls consciousness and alertness. The cerebellum maintains muscle tone, coordinates muscle movement, and controls balance. The thalamus is a relay system for sensory stimuli. The hypothalamus controls body temperature.

Which of the following interventions are best for preventing sensory deficit for a resident in a long-term care facility? Select all that apply. a) Talk to the patient as you provide care. b) Incorporate touch when providing care. c) Turn on bright, fluorescent light for reading. d) Encourage waiting to drink water until after the meal. e) Offer spicy seasoning for the resident to use on food.

ANS: A, B Talking to the patient while providing care is not only important for personal and meaningful interaction, but also reduces social isolation and sensory deprivation. If the patient consents, you can stimulate the sense of touch by brushing his hair or giving a back rub, for example. However, use touch carefully, considering personal and cultural preferences, while observing the patient's reaction. Provide enough light, but avoid glare; use soft, diffuse lighting, not bright, fluorescent light. Teach clients to drink water between bites (not waiting until after the meal) to distinguish the taste of the food more readily. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods and encourage the client's appetite. But avoid overseasoning food with excessively spicy food that overpowers the person's sense of taste.

The nurse caring in the intensive care unit suspects that one of her patients is experiencing sensory overload. Which findings would increase her suspicion? Select all that apply. a) Disorientation b) Restlessness c) Hallucinations d) Depression e) Preoccupation with somatic complaints

ANS: A, B The patient with sensory overload might exhibit disorientation, confusion, restlessness, decreased attention span and ability to perform tasks, anxiety, muscle tension, and difficulty sleeping. Sensory deprivation also leads to irritability, confusion, reduced problem-solving, and impaired attention span; but unlike sensory overload, the person with sensory deficit experiences depression, preoccupation with somatic complaints, hallucinations, and delusions.

Sensory changes that occur with aging include which of the following? Select all that apply. a) Decreased number of nerve conduction fibers results in slower reflexes. b) The lens of eye becomes less flexible and less able to focus on near objects. c) Taste buds atrophy and decrease in number, causing decreased ability to perceive taste. d) Impaired regulation of body temperature causes an increased risk for seizures. e) The amount and waxiness of cerumen increases with aging.

ANS: A, B, C A decreased number of nerve conduction fibers resulting in slower reflexes, less flexibility of the lens resulting in decreased ability to focus on near objects, and atrophy of taste buds resulting in decreased ability to taste are all sensory changes that occur with aging. Regulation of body temperature is not a sensory deficit. Cerumen is drier and more solid with aging, creating hearing loss.

Which of the following populations are considered high risk for sensory deprivation? Select all that apply, a) The homebound b) Those in prison c) Those who are depressed d) Those experiencing high anxiety e) Those feeling pain

ANS: A, B, C A nonstimulating, monotonous environment increases the risk for sensory deprivation, such as people who are in prison or who are homebound. Patients with depression are at risk for sensory deprivation, as they might be withdrawn from others and activities or less apt to interact within the usual context of their lives. Patients with anxiety often experience sensory overload. Pain lowers the threshold for processing sensory input, which increases the risk for sensory overload.

Which of the following medical conditions has a direct effect on sensory function contributing to sensory deficits? Select all that apply. a) Diabetes b) Hypertension c) Multiple sclerosis d) Breast cancer e) Zinc deficiency

ANS: A, B, C, E Diseases that affect circulation may impair function of the sensory receptors and the brain, thereby altering perception and response. Some diseases affect specific sensory organs. Diabetic retinopathy is the leading cause of blindness among adults ages 20 to 74. Hypertension, too, can damage the retina of the eyes. Neurological disorders, such as multiple sclerosis, slow the transmission of nerve impulses. There is no indication that breast cancer leads to sensory deficits. Zinc deficiency can cause anosmia, which is reduced sense of smell.

Which of the following areas would the nurse include in a mental status assessment for an adult patient? Select all that apply. a) Behavior b) Judgment c) Knowledge d) Reflexes e) Appearance

ANS: A, B, C, E The mental status assessment includes assessment of behavior, appearance, response to stimuli, speech, memory, and judgment. Normal findings include an ability to express and explain realistic thoughts with clear speech, follow directions, listen, answer questions, and recall significant past events. Assessment of reflexes is associated with a complete and in-depth neurological assessment.

The pediatric nurse educator is preparing a teaching plan for seizure prevention for parents of children with seizures. Which of the following can trigger seizures? Select all that apply. a) Fever b) Video games c) Sleep deprivation d) Food allergens e) Mood-altering substances

ANS: A, B, C, E The most common reason for seizures in a person with epilepsy is failure to take prescribed antiseizure medication. Other common triggers of seizures are illness and fever, sleep deprivation, stress, and ingestion of mood-altering substances. Additionally, high-contrast patterns and flashing or flickering lights (video games, strobe lights) can provoke seizure activity. Ingesting a food allergen invokes an immunological response with reactions related to anaphylaxis.

For a patient with dementia, how might the nurse best improve orientation and clarity? Select all that apply. a) Place personal objects where the patient can see them. b) Introduce yourself each time you have contact with the patient. c) Encourage the patient to relax while the nurse gives the bath. d) Use short sentences with only a few words. e) Do not offer many choices when it comes to ADLs.

ANS: A, B, D, E Place personal objects, photos, and mementos in the immediate environment, and discuss them with the client. Introduce yourself and state the client's name each time you meet with him; wear a readable (large, plain type) nametag to reinforce your introduction. Also identify the day, date, and time as you interact. Encourage the patient to participate in familiar activities, such as bathing. To promote patient orientation for a patient with confusion (e.g., dementia), use simple communication and offer few choices with ADLs to prevent from overwhelming the patient. While you may sometimes find it necessary to bathe the patient, that intervention wouldn't be expected to improve orientation. Furthermore, encouraging the patient to relax would likely be ineffective in relaxing the patient, and might even elicit anger.

What are some positive effects of pet therapy for residents in a long-term care facility? Select all that apply. a) Increases socialization b) Increases blood pressure c) Decreases pain d) Decreases loneliness e) Decreases insomnia

ANS: A, C, D Many facilities have resident pets or can arrange to have pets visit. Pet therapy can increase socialization, lower blood pressure, and decrease loneliness and perception of pain.

For an unconscious patient, which of the following interventions are necessary to provide for patient safety? Select all that apply. a) Talk to the patient as you provide care. b) Incorporate more touch in the plan of care. c) Give frequent eye care if blink reflex is absent. d) Keep the siderails up and bed in low position. e) Perform diligent oral care by irrigating with diluted mouthwash.

ANS: A, C, D Safety measures are a priority for unconscious clients. Keep the bed in low position when you are not at the bedside, and keep the siderails up. If the patient's blink reflex is absent or her eyes do not close totally, you may need to give frequent eye care to keep secretions from collecting along the lid margins. The eyes may be patched to prevent corneal drying, and lubricating eye drops may be ordered. It is important to talk to the patient because the sense of hearing may still be intact. This provides some stimulation and may help with reality orientation. Providing touch will also help prevent sensory deficit; however, it is not a safety measure. The unconscious patient would have a minimal or absent gag reflex and lack of swallowing; therefore, you would not squirt fluid in the mouth for oral care because it could cause the patient to aspirate.

Which factors in a health history place a patient at risk for hearing loss? Select all that apply. a) Being an older adult b) Childhood chickenpox c) Frequent otitis media d) Diabetes mellitus e) Congenital rubella

ANS: A, C, E Having had frequent ear infections (otitis media) places a patient at risk for hearing loss because of scarring that may have occurred. Older adults experience a generalized decrease in the number of nerve conduction fibers and structural changes in the ear, which cause hearing loss. Sensorineural deafness, eye abnormalities, and congenital heart disease are the classic triad that occurs with congenital rubella. Chickenpox and diabetes mellitus do not place the patient at risk for hearing loss.

For a patient with hearing loss, it is essential to minimize the risk of further damage to the auditory nerve. Which of the following medications may need to be discontinued if the patient is taking them? Select all that apply. a) Furosemide, a diuretic b) Digoxin, a cardiotonic c) Famotidine, an antacid d) Aspirin, an analgesic e) Penicillin, an antibiotic

ANS: A, D Aspirin and furosemide may cause ototoxicity, leading to auditory nerve impairment. Digoxin, famotidine, or penicillin does not place the patient at risk for auditory nerve impairment.

The 80-year-old patient on the medical-surgical unit says to the nurse, "My vision is blurry and I see halos around lights. The glare from the sun really bothers me." Upon assessment, the nurse notes a cloudy film over the lens of the eye. Based on the patient's complaints and the nurse's assessment, the nurse associates these findings with which of the following? a) Strabismus b) Cataracts c) Glaucoma d) Presbyopia

ANS: B A cataract is a cloudy film over the lens of the eye resulting in blurred vision, sensitivity to glare and bright light, halos around lights, fading or yellowing of colors, and image distortion. Tinnitus is ringing in the ear unrelated to vision. Presbyopia is a change in vision associated with aging in which a person is less able to accommodate to near objects. Glaucoma is a condition involving increasing pressure in the eye that can lead to loss of peripheral vision and even blindness, if not treated. Strabismus ("crossed-eyes") is the condition wherein one eye deviates from a fixed image.

The nurse has been teaching a parent about stimuli to develop her infant's auditory nervous system. Which behavior by a parent toward the child provides evidence that learning occurred? a) Cuddling b) Speaking c) Feeding d) Soothing

ANS: B Exposure to voices, music, and ambient sound helps develop the infant's auditory nervous system. Cuddling, feeding, and soothing provide comfort and pleasure and teach the infant about his external environment.

A patient comes to the clinic complaining of a taste disturbance. Which medication that the patient is currently prescribed is most likely responsible for this disturbance? a) Furosemide, a diuretic b) Phenytoin, an anticonvulsant c) Glyburide, an antidiabetic d) Heparin, an anticoagulant

ANS: B Phenytoin is a medication that has a high incidence of associated taste disturbance. Furosemide, glyburide, and heparin are not implicated in taste disturbances.

The nurse checks a patient's pupils using a penlight. Which receptors is the nurse stimulating? a) Chemoreceptors b) Photoreceptors c) Proprioceptors d) Mechanoreceptors

ANS: B Photoreceptors located in the retina of the eyes detect visible light. Proprioceptors in the skin, muscles, tendons, ligaments, and joint capsules coordinate input to enable an individual to sense the position of the body in space. Chemoreceptors are located in the taste buds and epithelium of the nasal cavity. They play a role in taste and smell. Thermoreceptors in the skin detect variations in temperature. Mechanoreceptors in the skin and hair follicles detect touch, pressure, and vibration.

After sustaining a stroke, the patient lacks attention to the right side of his body. Which nursing diagnosis best describes the patient's problem? a) Disturbed Sensory Perception b) Unilateral Neglect c) Risk for Peripheral Vascular Dysfunction d) Acute Confusion

ANS: B This patient lacks attention to the right side of his body after sustaining a stroke; therefore, the most appropriate nursing diagnosis is Unilateral Neglect. The patient may also have Disturbed Sensory Perception, Risk for Peripheral Vascular Dysfunction, and Acute Confusion, but they are not the most appropriate for the defined problem.

Which actions can the nurse take to prevent sensory overload? Select all that apply. a) Leave the television on low volume to block out other noises. b) Minimize ambient light in the patient's room. c) Plan care to provide periods of sleep. d) Speak with a moderate tone of voice. e) Restrict caffeine intake during hospitalization.

ANS: B, C, D, E To prevent sensory overload, minimize unnecessary light, plan care to provide uninterrupted periods of sleep, and speak to the patient in a moderate tone of voice using a calm and confident manner. Television can be used to provide sensory stimuli, but not to prevent sensory overload. When used, it should not be left on indiscriminately. Medications and some substances that stimulate the CNS may also contribute to sensory overload, such as caffeine.

The nurse in the intensive care unit enters her patient's room and observes the patient is experiencing a seizure. What are the most appropriate interventions by the nurse? Select all that apply. a) Insert a padded tongue depressor in the patient's mouth. b) Turn the patient to his side. c) Restrain the patient to control his jerking movements. d) Loosen any restrictive clothing. e) Pad the siderails of the patient's bed.

ANS: B, D, E When a seizure is occurring, the nurse would turn the patient to his side to prevent aspiration and loosen any restrictive clothing; also pad the head, foot, and siderails of the bed and place oral suction at the bedside. Do not try to open the mouth and insert a tongue depressor. This action could result in injury to the patient or injury to the nurse (biting). Also do not attempt to restrain the patient, as this may result in muscle and joint injury.

The patient at the clinic says to the nurse, "My doctor checked my eyes and told me my vision was 20 over 100 [20/100]. What does that mean?" What is the best response by the nurse? a) "This means that your eye pressure readings are quite high and may be indicative of glaucoma." b) "These are numbers associated with left and right eye readings for identifying macular degeneration." c) "This could be nearsightedness. Your vision for seeing objects up close is better than your vision for seeing things in the distance." d) "This could be that you are farsighted. Your vision for seeing objects in the distance is better than it is for seeing objects up close."

ANS: C Myopia, or nearsightedness, means that the person is able to see close objects well but not distant objects. For example, a person with 20/100 vision can see an object from 20 feet away that a person with normal sight could see from a distance of 100 feet. Hyperopia, or farsightedness, implies that the eye sees distant objects well. A person with hyperopia may have 20/10 vision—he can see an object form 20 feet that a normal eye can see from 10 feet. Glaucoma is a type of vision loss caused by increased pressure in the anterior cavity of the eyeball resulting in loss of peripheral vision. The fraction 20/100 is unrelated to glaucoma. Macular degeneration is the loss of central vision due to damage to the macula lutea, the central portion of the retina. This results in loss of central and near vision. The fraction 20/100 is unrelated to identifying macular degeneration.

Which essential oil might the nurse trained in aromatherapy use to uplift and stimulate a patient? a) Lavender b) Roman chamomile c) Rosemary d) Ylang-ylang

ANS: C Rosemary is stimulating and uplifting for many people. Lavender, Roman chamomile, and ylang-ylang are used to promote relaxation.

The nurse is caring for a patient with dementia who becomes agitated every evening. Which intervention by the nurse is best for calming this patient? a) Encouraging family members to visit only during the day b) Applying wrist restraints during periods of agitation c) Playing soft, calming music during the evening d) Administering lorazepam (a tranquilizer)

ANS: C Soft, calming music is sometimes helpful for patients with dementia. Encouraging a family member to sit with the patient might have a calming effect, but the option does not provide for that during the evening when the patient is symptomatic. Applying bilateral wrist restraints might further agitate the patient. Lorazepam will provide sedation but might cause further confusion.

Which intervention is appropriate for the patient with a nursing diagnosis of Disturbed Sensory Perception: Gustatory? a) Limit oral hygiene to one time a day. b) Teach the patient to combine foods in each bite. c) Assess for sores or open areas in the mouth. d) Instruct the patient to avoid salt substitutes.

ANS: C The nurse should assess for sores or open areas in the mouth and provide frequent oral hygiene. The nurse should also teach the patient to eat foods separately to allow the taste of food to be distinguishable. Seasonings, salt substitutes, spices, or lemon may improve the taste of foods, so the patient should not avoid them.

The nurse must irrigate the ear of a 4-year-old child. How should the nurse pull the pinna to straighten the child's ear canal? a) Up and back b) Straight back c) Down and back d) Straight upward

ANS: C The nurse should straighten the ear canal of a small child by pulling the pinna down and back. To straighten the ear canal of an adult, the nurse should pull the pinna up and outward.

A patient complains of an impaired sense of smell. Which cranial nerve might have been affected? a) Trigeminal b) Glossopharyngeal c) Olfactory d) Vagus

ANS: C The olfactory nerve is responsible for the sense of smell. Damage to this nerve causes an impaired sense of smell. The trigeminal nerve transmits stimuli from the face and head. The glossopharyngeal nerve is responsible for taste. The vagus nerve is responsible for sensations of the throat, larynx, and thoracic and abdominal viscera.

Which nursing diagnosis has the highest priority for a patient with impaired tactile perception? a) Self-Care Deficit: Dressing and Grooming b) Impaired Adjustment c) Risk for Injury d) Activity Intolerance

ANS: C The patient with impaired tactile perception is unable to perceive touch, pressure, heat, cold, or pain, placing him at risk for injury. Self-Care Deficit: Dressing and Grooming, Impaired Adjustment, and Activity Intolerance are also likely to be appropriate for this patient, but are not as high a priority as Risk for Injury. Risk for Injury is directly related to safety, which must always be a priority.

The home health nurse is developing a plan of care for her patient with a visual impairment. What is the priority nursing diagnosis for this patient? a) Self-Neglect b) Social Isolation c) Risk for Falls d) Risk for Imbalanced Nutrition: Less Than Body Requirements

ANS: C The priority nursing diagnosis for a patient with a visual impairment is Risk for Falls. The patient, owing to a visual impairment, may have deficits with feeding, dressing, and social interaction; however, the highest priority is promoting safety and reducing the patient's risk for falls.

The nurse is assessing an elderly male in the nursing home. What question will the nurse ask this patient to best assess his level of orientation? a) "Will you please repeat these three words for me: glasses, rocket, truck?" b) "Can you tell me the date of your retirement from your workplace?" c) "What is your name and today's date? Can you tell me where you are?" d) "What did you eat for breakfast this morning?"

ANS: C To assess level of orientation, the best question is to ask the patient for his name, date, and his current location. Asking the patient to repeat a sequence of words (e.g., glasses, rocket, truck) assesses recall and recent memory. Asking a patient for the date of retirement assesses long-term memory but does not reflect the patient's orientation status to the present time and situation. Asking a patient what he ate for breakfast assesses short-term memory only.

Which of the following tasks may be delegated to a certified nursing assistant (CNA)? Select all that apply. a) Irrigating the ear of a child with impacted cerumen b) Administering eye drops for a patient in a coma c) Obtaining vital signs every 15 minutes after a seizure d) Padding the sides of a bed for seizure precautions e) Suctioning the patient's oropharynx after a seizure

ANS: C, D A CNA may obtain vital signs and suction the patient's oropharynx postseizure and may perform the tasks of setting up seizure precautions, which includes padding the side of the bed to prevent injury. A CNA may not perform ear irrigation or administer eye drops, as these interventions require knowledge, skills, and assessment of the professional nurse.

A patient who sustained a head injury in a motor vehicle accident has damage to the temporal lobe. This injury places the patient at risk for which type of hearing loss? a) Otosclerosis b) Conduction deafness c) Presbycusis d) Central deafness

ANS: D Central deafness results from damage to the auditory areas in the temporal lobes. Otosclerosis is hardening of the bones of the middle ear, especially the stapes. Conduction deafness results when one of the structures that transmits vibrations is affected. Presbycusis is a progressive sensorineural loss associated with aging.

The nurse caring for a fussy newborn uses which of the following interventions to calm the baby and reduce sensory overload? a) Rubbing the baby's back b) Singing and rocking the baby c) Hanging a black and white mobile d) Swaddling the baby tightly

ANS: D In the first months of life until the autonomic nervous system matures, newborns are easily overstimulated by the loud noises, bright light, high-contrast objects (e.g., black and white mobile), and stroking sensitive areas (back and bottom of feet). Stroking the back or bottom of feet can be too much for the baby to handle. Newborns experience sensory overload, particularly when more than one sense is involved, such as singing (auditory) and rocking (kinesthetic).

A patient complains to the nurse that since taking a medication he has suffered from excessively dry mouth. What term should the nurse use to document this complaint? a) Exophthalmos b) Anosomia c) Insomnia d) Xerostomia

ANS: D The nurse should document excessively dry mouth as xerostomia. Exophthalmos is abnormal bulging of the eyeballs that commonly occurs with thyrotoxicosis. Anosomia is losing the sense of smell. Insomnia is inability to sleep.

Which instruction should the nurse be certain to include when providing discharge teaching for a patient who has a serious visual deficit? a) Install blinking lights to alert an incoming phone call. b) Have gas appliances inspected regularly to detect gas leaks. c) Wear properly fitting shoes and socks. d) Avoid using throw rugs on the floors.

ANS: D The nurse should instruct the visually impaired patient to avoid using throw rugs on the floors at home. She should instruct the patient with a hearing deficit to install blinking lights to alert him to an incoming phone call. She should instruct the patient with an olfactory deficit to have gas appliances inspected regularly to detect leaks. The patient with a tactile deficit should be instructed to use properly fitting shoes and socks.

Which intervention is helpful when caring for a patient with impaired vision? a) Suggest the patient use bright overhead lighting. b) Advise the patient to avoid wearing sunglasses when outdoors. c) Do not offer large-print books, as this may embarrass the patient. d) Place the patient's eyeglasses within easy reach.

ANS: D The nurse should place the patient's eyeglasses within easy reach and make sure that they are clean and in good repair. The patient should have sufficient light but avoid bright light, which might cause glare. The patient should be encouraged to wear sunglasses, visors, or hats with brims when outdoors. A magnifying lens or large-print books may be helpful.