PREP U SENSORY

Which behavior typical of children with autism spectrum disorder (ASD) requires you to maintain special care to keep them safe? a. A fascination with bright colors b. Loss of hearing for high frequencies c. A craving for salt d. Insensitivity to pain

Correct response: Insensitivity to pain Explanation: A number of children with ASD demonstrate poor sensation of pain and, thus, bite their hands or bang their heads repeatedly.

A group of students are reviewing the various causes of bacterial conjunctivitis in children. The students demonstrate understanding of this condition when they identify what as the most common cause? a. Streptococcus pneumoniae b.Chlamydia trachomatis c.Haemophilus influenzae d. Staphylococcus aureus

Correct response: Staphylococcus aureus Explanation: S. aureus is the most common bacterial cause of conjunctivitis. Although a common cause, S. pneumoniae is not the most common cause of bacterial conjunctivitis. Although a common cause, H. influenzae is not the most common cause of bacterial conjunctivitis. Although a common cause, C. trachomatis is not the most common cause of bacterial conjunctivitis.

The nurse would include which of the following in a neurological assessment?

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.

The nurse is caring for a 6-month-old infant diagnosed with otitis media. Which of the following clinical manifestations would likely have been noted in this child? a) Severe vomiting and confusion b) High-pitched cry and nuchal rigidity c) Shaking the head and pulling the ear d) Body stiffening and loss of consciousness

Answer: Shaking the head and pulling the ear Explanation: A restless infant who repeatedly shakes the head and rubs or pulls at one ear should be checked for an ear infection.

Which of the following situations demonstrates sensory adaptation? A patient with hearing loss has learned to communicate using sign language. B. A patient has learned to sleep through the frequent beeping of her intravenous pump. A patient believes his hearing has become more acute since he lost his vision. A patient with vision loss has begun buying large-print books.

B. Adaptation occurs when the body adapts to constant stimuli, such as the continuous beeping of a hospital device. Adaptation is not the same as the compensation in routines or other senses that occurs when patients experience sensory losses.

Which of the following is an indicator of neurovascular compromise? Warm skin temperature Capillary refill of more than 3 seconds Pain on active stretch Diminished pain

Capillary refill of more than 3 seconds is an indicator of neurovascular compromise. Other indicators include cool skin temperature, pale or cyanotic color, weakness, paralysis, paresthesia, unrelenting pain, pain on passive stretch, and absence of feeling. Cool skin temperature is an indicator of neurovascular compromise. Unrelenting pain is an indicator of neurovascular compromise. Pain on passive stretch is an indicator of neurovascular compromise.

A child's pain tolerance refers to the point at which the child first senses pain. TRUE OR FALSE

Correct response: False Explanation: A child's pain threshold refers to the point at which the child first senses pain. This varies greatly from person to person and is probably most influenced by heredity. All people also have a point above which they are not willing to bear any additional pain. This is a person's pain tolerance.

The nurse is employed in a neurologist's office, performing a history and assessment on a client experiencing hearing difficulty. The nurse is most correct to gather equipment to assess the function of which cranial nerve?

There are 12 pairs of cranial nerves. Cranial nerve VIII is the vestibulocochlear or auditory nerve responsible for hearing and balance. Cranial nerve II is the optic nerve. Cranial nerve VI is the abducens nerve responsible for eye movement. Cranial nerve XI is the accessory nerve and is involved with head and shoulder movement.

A client seeks care for lower back pain of 2 weeks' duration. Which assessment finding suggests a herniated intervertebral disk? a. Pain radiating down the posterior thigh b. Back pain when the knees are flexed c. Atrophy of the lower leg muscles d. Homans' sign

a.Pain radiating down the posterior thigh ration: A herniated intervertebral disk may compress the spinal nerve roots, causing sciatic nerve inflammation that results in pain radiating down the leg. Slight knee flexion should relieve, not precipitate, lower back pain. If nerve root compression remains untreated, weakness or paralysis of the innervated muscle group may result; lower leg atrophy may occur if muscles aren't used. Homans' sign is more typical of phlebothrombosis.

To give birth to her infant, a woman is asked to push with contractions. Which pushing technique is the most effective and safest? a. lying on side, arms grasped on abdomen b. lying supine with legs in lithotomy stirrups c.squatting while holding her breath d. head elevated, grasping knees, breathing out

d. An important point is to be certain the woman does not hold her breath, as this puts pressure on the vena cava, reducing blood return.