Module 18- Sensory Perception

2) The nurse determines that a client is at risk for developing cataracts. What did the nurse assess in this client? A) Age 75 years B) Hypertension C) Minimal direct sun exposure D) Nonsmoker

a

4) A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. What will the nurse use to assess this client? A) Rosenbaum eye chart B) Penlight C) Cover-uncover test D) Snellen eye chart

a

5) A client with impaired hearing is scheduled for a test to measure the compliance of the middle ear to sound transmission. For which diagnostic test will the nurse instruct the client? A) Tympanometry B) Weber test C) Rinne test D) Whisper test

a

5) The nurse has identified the diagnosis Disturbed Sensory Perception: Auditory for a client. Which intervention would be the most appropriate for this client? A) Replace batteries in hearing aids every week. B) Use facial expressions or gestures when talking. C) Face the client when speaking. D) Use a low voice pitch with normal loudness when talking.

a

6) The nurse is evaluating the care a client with a hearing deficit has received. Which client statement indicates that care has been effective? A) "I ask others to face me when they talk, as I can hear them better." B) "I hear better when the television volume is raised." C) "I will change the battery in my hearing aid once a month." D) "I might use the hearing aid when I go shopping."

a

7) A client tells the nurse about plans to become pregnant. What should the nurse provide to ensure healthy sensory functioning of the newborn? A) Testing for rubella B) The need to limit vitamin A intake C) Importance of ingesting zinc D) Avoiding foods high in folic acid

a

9) A nurse is caring for a client with a genetic nerve disorder who has a deficit when attempting to move the tongue. When performing the nursing assessment, the nurse understands that this deficit relates to which cranial nerve? A) XII B) XI C) VIII D) VI

a

5) The nurse is planning care for a client scheduled for cataract surgery. Which interventions should the nurse include in this client care plan? Select all that apply. A) Instruct on the administration of eye drops. B) Wear sunglasses if necessary. C) Avoid strenuous activity until seen by the ophthalmologist after the surgery. D) Resume normal activities of daily living after the procedure. E) Limit food and fluids until fully recovered from anesthesia.

a, c

10) A client is recovering from cochlear implant surgery. What is true regarding cochlear implants? A) They restore normal hearing to those who could not hear any sound prior to implantation. B) Their function is more similar to the way the ear normally receives and processes sounds than it is to that of a hearing aid. C) They may be the only hope for restoring sound perception for the client with a total and permanent hearing loss. D) With implantation, the structures

b

2) The nurse identifies potential safety concerns for a client with a sensory disorder. Which intervention should the nurse include in this client's plan of care? A) Teach how to adapt to the sensory deficit. B) Identify assistive devices. C) Provide meaningful interaction and stimulation. D) Teach the need to take antibiotics as prescribed.

b

7) A client has been diagnosed with cataracts of both eyes. What should the nurse realize that the treatment of choice for this client will be? A) Treat the cataracts with corrective lenses. B) Remove one cataract and then, in a few weeks, remove the other cataract. C) Remove both cataracts at the same time. D) Treat the cataracts with eye drops.

b

8) A client with glaucoma is experiencing sensory overload. What can the nurse suggest to reduce this client's visual overstimulation? A) Do not go outside during the daytime. B) Wear sunglasses that block UVA and UVB rays. C) Insert artificial tears several times a day. D) Use an over-the-counter eye drop for irritation.

b

8) The nurse is reviewing discharge instructions with a client recovering from out-client cataract removal surgery. What should these instructions include? A) Phone the physician with any signs of eye drainage. B) Do not bend to pick up objects. C) Healing will be complete in 2 weeks. D) Wear the eye patch the day of surgery only.

b

9) A nurse is caring for a client who is receiving IV tobramycin for the treatment of a respiratory infection. On which sensory factor will the nurse focus when concerned about this medication's toxic effects on the body? A) Taste B) Hearing C) Vision D) Swallowing

b

Exemplar 18.2 Cataracts 1) After being diagnosed with cataracts, a client believes the right eye has a cataract but not the left eye, as there are no vision changes with the left eye. What should the nurse respond to this client? A) "Only your physician can tell if you have a cataract in your left eye." B) "Cataracts develop at different rates, so one eye will be more affected than the other." C) "Don't worry about it until you can't see out of your left eye." D) "Your physician must have made an error."

b

7) The nurse is planning care for a client with an uncorrectable hearing loss. Which strategies for communication should the nurse add to the client's plan of care? Select all that apply. A) Magic slate B) Total communication C) Hearing aids D) Cued speech E) Sign languag

b, d, e

2) An older client, reporting a significant loss of hearing after being involved in an explosion, asks when hearing will return. Which response by the nurse is most appropriate at this time? A) Surgery will help restore the hearing you have lost. B) The most common cause of hearing impairments is exposure to loud noises. C) Loud noises can cause immediate, permanent loss of hearing. D) Hearing loss attributed to loud noises is normally reversible.

c

3) The nurse is providing instruction to the parents of a 7-month-old child who has just been diagnosed with hearing loss. What guidance should the nurse provide? A) Hearing loss is not serious until 1 year of age. B) Interventions to support hearing are not useful until the child is at least 9 months old. C) Expect that your child will be enrolled in a special hearing intervention program immediately. D) Keep your child in a quiet environment until additional testing is done.

c

4) An older client with bilateral cataracts, arthritis, and a hearing deficit is scheduled for cataract surgery. Which nursing diagnosis would be a priority for this client? A) Disturbed Sensory Perception: Visual B) Decisional Conflict C) Risk for Ineffective Health Maintenance D) Ineffective Coping

c

4) The nurse is identifying diagnoses appropriate for a client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. Which diagnosis would be a priority for this client? A) Imbalanced Nutrition: Less than Body Requirements B) Disturbed Sleep Pattern C) Risk for Injury D) Disturbed Sensory Perception: Auditory

c

8) The nurse is providing care to a client with a hearing deficit. Which intervention should the nurse use when providing care to this client? A) Overarticulate words. B) Vary the volume of voice through sentences. C) Face the client during conversation. D) Use short phrases.

c

3) The nurse is planning care for an older client with early dry macular degeneration. What should the nurse expect the client will be prescribed? Select all that apply. A) Laser surgery B) Eye patches C) Antioxidants D) Eye drops E) Zinc

c,e

10) Which nursing action is most appropriate when communicating with a client who has a hearing deficit? A) Over articulating words in order for the client to understand B) Using shorter phrases, which tend to be easier to understand than longer ones C) Varying the volume of voice, which is easier to understand than one consistent volume D) Writing ideas or pantomiming as appropriate in order for the client to understand

d

3) The mother of a premature newborn asks the nurse why the baby's eyes are cloudy. What should the nurse respond to the mother? A) "It is because of an allergic reaction." B) "It happens with most newborns." C) "It is because you developed an illness while carrying the baby before birth." D) "It is seen with premature infants."

d

6) The nurse is preparing a seminar for community members on actions to protect sensory functioning when aging. What should the nurse recommend regarding hearing tests for older adults? A) Schedule an annual hearing test until the age of 50 and then have a test every 6 months. B) A hearing test is needed when changing medications. C) A hearing test should be done biannually after the age of 60. D) Have a hearing test every 10 years until age 50 and then every 3 years.

d

6) The nurse provides postoperative teaching to a client recovering from cataract removal surgery. Which client statement indicates that preoperative teaching has been effective? A) "I will be hospitalized for several days recovering from this surgery." B) "I will need to return to activity as soon as possible." C) "I will use the eye drops if I have eye pain" D) "I will notify the doctor if I have itching or redness of the eye after the surgery."

d

A client recovering from surgery to repair fractured bones in the face tells the nurse that dinner "tastes horrible." What should the nurse respond to this client? A) "The meal on your tray is the best the cafeteria has to offer today." B) "Let me see if I can order something else for you from the cafeteria." C) "You do not have to eat anything you don't want to." D) "The facial injuries are affecting your sense of taste and flavor."

d

Exemplar 18.1 Hearing Impairment 1) The nurse suspects that a client has a hearing disorder; however, the client denies not being able to hear. What initial action should the nurse take to assess the client's hearing? A) Use an otoscope to visualize the inner ear. B) Schedule a Weber and Rinne test. C) Confront the client with the suspicion. D) Observe the client's interaction with family.

d