sensory final exam questions
A home safety measure specific for a client with diminished olfaction is the use of: 1 Smoke detectors on all levels 2 Extra lighting in hallways 3 Amplified telephone receivers 4 Mild water heater temperatures
1
During a home safety assessment, the nurse identifies that there are a number of hazards present. Of the following hazards that are noted by the nurse, which one represents the greatest risk for this client with diabetic peripheral neuropathy? 1 Improper water heater settings 2 Absence of smoke detectors 3 Cluttered walkways 4 Lack of bathroom grab bars
1
Following a brain attack, the 45-year-old female client was very confused She was having difficulty responding appropriately to the nurse and to her family members. The clients daughter was concerned that her mother was suffering from a mental breakdown, even though she had no history of mental illness. The best information that the nurse can share with the clients daughter is: 1 Your mother appears to have aphasia as a result of her stroke. 2 Your mother will be just fine in no time. 3 Your mother has been through a lot as a result of her stroke. 4 We can have a psychiatric workup done if you would like.
1
The 85-year-old female client has moved to an assisted living apartment so that she can remain independent yet have some limited assistance with her ADLs. Which of the following suggestions should the nurse make that would be most appropriate to reduce sensory deprivation? 1 Provide pictures of the clients family. 2 Purchase all-new furnishings. 3 Suggest that the client take all her meals in her apartment until she gets the chance to know her neighbors better. 4 Ask family and friends to wait a few days to visit until the client has an opportunity to settle in.
1
The daughter of a client recently admitted to a skilled nursing facility shares with the nurse that she is concerned about how disinterested her mother seems in everyone and everything around her. The most therapeutic response by the nurse is: 1 Bring something from home for her to display in her room 2 It is most likely just her way of adjusting to leaving her home 3 Many of the residents have this problem when they first come here 4 Just give her time to adjust; shell get more involved in a few days
1
The family of an older client asks the nurse how the stairways and hallways in the home may be enhanced to promote safety. In addition to extra lighting, the nurse recommends the use of paint and decorations that are: 1 Red and yellow 2 Black and white 3 Brown and green 4 Blue and purple
1
The nurse is discussing vision and hearing health with a group of senior citizens. Which of the following individuals should be given special encouragement to have regular eye screenings for the presence of glaucoma? 1 An African American with hypertension 2 An Asian with osteoarthritis in the hands 3 A white with peripheral vascular disease 4 A Hispanic with type 2 diabetes
1
The nurse is preparing a 70-year-old visually impaired male client for home discharge. Which of the following nursing actions will have the greatest impact on the clients safety related to medication administration? 1 Evaluate the clients ability to read the frequency and dosage information on his medication bottles. 2 Watch the client demonstrate the appropriate method for splitting his morning medication in half. 3 Observe the client open and pour out the appropriate number of pills required for his morning medications. 4 Have the client restate the administration schedule and prescribed dosage of each of his home medications.
1
The nurse notes that the 43-year-old male blind client who has had a stroke is not having difficulty recognizing an object by touch. This sense is known as: 1 Stereognosis 2 Auditory 3 Gustatory 4 Olfactory
1
The nurse teaches a client that prolonged use of the antibiotic streptomycin may result in: 1 Damage to the auditory nerve 2 Alteration in perception 3 Optic irritation 4 Loss of taste
1
Which of the following occupations poses the least risk for sensory alterations? 1 Waiter 2 Welder 3 Computer programmer 4 Construction worker
1
Which of the following safety measures is most important for the nurse to implement for a hospitalized client with a visual impairment? 1 Orient the client to the room. 2 Open the window blinds to let in light. 3 Keep the clients door to the room open so that he or she can be visualized. 4 Keep all four side rails up to remind the client not to get up on his or her own.
1
Which of the following statements made by the nurse shows the greatest insight into the possible causes of a hearing-impaired clients irritability? 1 I know he doesnt hear well, but I wonder if his increased lack of patience today has to do with being in pain. 2 Not being able to hear us properly appears to be making him irritable today. See if he has his hearing aid turned off. 3 His hearing aids must need new batteries; he is just so irritable and impatient today. 4 He is certainly irritable today, but maybe it doesnt have to do with his poor hearing.
1
While participating in a community auditory screening, the nurse is alert to the population that has the greatest prevalence of problems. The nurse is aware that hearing impairment is more common for: 1 Whites 2 Asian Americans 3 African Americans 4 Native Americans
1
Which of the following physical assessments are essential when attempting to determine the presence of sensory deficits in an older adult client? (Select all that apply.) 1 Vision 2 Hearing 3 Smell 4 Taste 5 Touch 6 Gait
1, 2, 3, 4, 5
The nurse is discussing vision changes that normally occur with aging with a group of older adults. Which of the following conditions should be included in the discussion? (Select all that apply.) 1 Poor night vision 2 Increased optical floaters 3 Reduced peripheral vision 4 Reduced depth perception 5 Increased sensitivity to glare 6 Diminished color perception
1, 3, 4, 5, 6
A 47-year-old male client has come in to his primary health care providers office for his annual checkup. The client shares with the nurse that his wife thinks he is suffering from hearing loss. Which of the following responses by the nurse would be most appropriate? 1 You are approaching an age when it is common to start having some hearing loss. 2 Do you work in a noisy environment? 3 You dont seem to have hearing problems to me. 4 Has anyone else noticed that you are having hearing problems?
2
For a client with receptive aphasia, which one of the following nursing interventions is the most effective? 1 Providing the client with a letter chart to use to answer complex questions 2 Using a system of simple gestures and repeated behaviors to communicate 3 Offering the client a notepad to write questions and concerns 4 Obtaining a referral for a speech therapist
2
It has been determined that a vision problem has contributed to a clients ability to provide self-care regarding bathing, dressing, and toileting. The initial nursing responsibility regarding these deficits is to: 1 Educate the clients family regarding the existing limitations so as to secure their support in meeting needs regarding activities of daily living (ADLs) 2 Arrange for in-home services to facilitate the clients ability to remain as independent as possible regarding ADLs 3 Provide the in-home care provider with sufficient information regarding the clients sensory deficits regarding ADLs 4 Provide sufficient client education regarding the in-home services available to help with ADL needs once discharge has occurred
2
The 25-year-old male client who has been in the trauma intensive care unit (ICU) for 3 weeks is confused and agitated. The nurse knows that this can happen to clients in an ICU setting due to: 1 Boredom 2 Sensory overload 3 Pain 4 A lack of stimulation
2
The client has hyperesthesia apparently associated with a neurological trauma. Which of the following is an appropriate nursing intervention in regard to the clients sense of touch? 1 Reminding the client of the need to have frequent tactile contact 2 Keeping the client loosely covered with sheets and blankets 3 Allowing the client to lie motionless 4 Using touch as a form of therapy
2
The nurse has completed the admission assessment for a client admitted to the hospitals subacute care unit. Of the following nursing diagnoses identified by the nurse, the one that takes the highest priority is: 1 Social isolation 2 Risk for injury 3 Risk-prone health behavior 4 Impaired verbal communication
2
The nurse is caring for a newly admitted client who is aphasic. The nurse most therapeutically addresses the communication issue by: 1 Evaluating the clients ability to express his or her needs by writing 2 Asking the client how he or she wants to communicate with the staff 3 Giving the client a pad and a pencil with which to communicate 4 Providing the client with an orientation to the use of the call bell
2
The nurse is working with a client with a moderate hearing impairment. To promote communication with this client, the nurse should: 1 Use a louder tone of voice than normal 2 Use visual aids such as the hands and eyes when speaking 3 Approach a client quietly from behind before speaking 4 Select a public area to have a conversation
2
The nurse is working with older adult clients in an extended care facility. To enhance the clients gustatory sense, the nurse should: 1 Mix foods together 2 Assist with oral hygiene 3 Provide foods of similar texture and consistency 4 Make sure foods are extremely spicy
2
Which of the following statements made by a client diagnosed with diabetes shows the most informed understanding of the effect of the disease on optic health? 1 The scariest part about having diabetes is the increased possibility of losing my eyesight. 2 I have my eyes checked yearly to be aware of any retinopathy that may be developing. 3 If I do a good job of keeping my blood sugars in line, I wont run such a risk for eye problems. 4 I try to keep my A1C below 7 so I can minimize the bad effects of hyperglycemia on my eyes.
2
A 79-year-old client drives his car in the local areas near his home. The most appropriate driving tip for the nurse to give this client is: 1 Go very, very slow so you will have some chance of reacting 2 Take your time on long road trips when you are by yourself 3 Remember to keep your car maintained with regular checkups 4 To avoid sun glare, you should drive at night
3
A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety even though the client has been reassured that his or her condition is improving and discharge to the unit will be occurring soon. The cause of the clients emotional state is a result of: 1 Fear of death 2 Social isolation 3 Sensory overload 4 Anxiety disorder
3
A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety, and the nurse believes the client is experiencing sensory overload. Which of the following interventions will be most therapeutic in assisting the client? 1 Limiting interaction with the client to the safe minimum 2 Moving the client to a space furthest from the nursing station 3 Keeping the clients lights dimmed and curtains partially drawn 4 Asking the clients health care provider to consider early discharge to the unit
3
A client is legally blind in both eyes. Which of the following is the most appropriate statement for the nurse to make to the client regarding providing the client with assistance? 1 I will walk in front of you, and you can hold onto my belt. 2 I know that you must need me to be your sighted guide to get around in this facility. 3 I will warn you of upcoming curbs or stairs. 4 I will get you a wheelchair so that I can move you around safely.
3
An older adult client in a nursing home has visual and hearing losses. The nurse is alert to which of the following signs that represents the effects of sensory deprivation? 1 Diminished anxiety 2 Improved task completion 3 Altered spatial perception 4 Decreased need for physical stimulation
3
During a community screening, the nurse informs a 50-year-old African American client about the frequency of eye examinations. It is recommended that individuals in this age-group have eye examinations: 1 Every 3 to 4 months 2 Every 6 months 3 Every 1 to 2 years 4 Every 4 years
3
The client has experienced a cerebral vascular accident (stroke) with resultant expressive aphasia. The nurse promotes communication with this client by: 1 Speaking very loudly and slowly 2 Speaking to the client on the unaffected side 3 Using a picture chart for the clients responses 4 Using hand gestures to convey information to the client
3
The client was working in the kitchen and was splashed in the face with a caustic cleaning agent. His eyes were affected, and he was brought to the hospital for treatment. After cleansing and evaluation, his eyes were bandaged. When assisting this client, who has temporary visual loss, to eat the nurse should: 1 Feed the client the entire meal 2 Allow the client to experiment with foods 3 Orient the client to the location of the foods on the plate 4 Assign ancillary personnel to feed the client
3
The nurse and a 62-year-old client are discussing the clients sense of hearing. Which of the following assessment questions is most likely to launch a conversation concerning the clients ability to hear effectively? 1 Do you think you have a hearing problem? 2 Do you hear as well as you did 5 years ago? 3 Would you rate your hearing as excellent, good, fair, poor, or bad? 4 Can you tell me when you believe you started to experience a hearing loss?
3
The nurse and a 69-year-old client are discussing the clients report of Not hearing as well as I used to; I must be getting old. Which of the following nursing responses is most therapeutic regarding the clients assumption of the cause of the diminished hearing? 1 What makes you think you dont hear as well as you used to? 2 Well, hearing loss does seem to be more of a problem as we age. 3 You may be right, but I suggest you see an otolaryngologist just to be sure. 4 Do you turn the television up louder, or is it difficult to hear on the telephone?
3
The nurse is discussing eye safety with a group of adults who regularly work around power tools. Which of the following questions should be the initial follow-up to the nurses inquiry, Do you own safety glasses? 1 Are they in good working order? 2 How long have you been using them? 3 Do you wear them each time you use your tools? 4 What do you think the advantage is to wearing them?
3
The nurse is visiting the day care center for routine assessment of the children. After spending time with the children in one of the playrooms, the nurse suspects that a child has a visual deficit as a result of observing: 1 Poor balance and gait 2 An increase in weight 3 Sitting and rocking back and forth 4 A failure to respond when touched
3
The wife of a 70-year-old client who is recuperating at home from hip replacement surgery expresses a concern to the nurse that He must be getting depressed. He just doesnt interact with people like he used to. Which of the following is the nurses most therapeutic response? 1 Are there any other signs of depressions? 2 Does he usually enjoy interacting with visitors? 3 Do you think he may be having difficulty hearing what people are saying to him? 4 Well he could be. Do you want me to see if his health care provider will order an antidepressant?
3
A 54-year-old client expresses concern about her weakening sense of smell to the nurse during an admission interview. The nurses most therapeutic response is: 1 I dont think it is anything to worry about, but you could mention it to your health care provider 2 That is really a fairly common complaint of people your age; I dont think there is anything to worry about 3 As long as you can smell things like smoke if there is a fire, I think it is something you need to get used to 4 As long as you can smell things like smoke if there is a fire, I think it is something you need to get used to
4
The nurse completes a safety assessment during a home visit to an older adult client. Of the following observations made by the nurse, the one that is of greatest concern for this client who has evidence of sensory impairment is: 1 Low-pile carpeting throughout the home 2 A handrail on the stairs that extends the full length 3 Higher wattage incandescent lighting in all the rooms 4 The gray/black settings on the stove handles
4
The nurse in the pediatric clinic is checking the basic visual acuity of a 4-year-old child. The nurse should have the child: 1 Use the standard Snellen chart 2 Read a few lines from a childrens book 3 Follow the peripheral movement of an object 4 Identify crayon colors
4
The nurse recommends follow-up auditory testing for a child who was exposed in utero to: 1 Excessive oxygen 2 Diabetes 3 Respiratory tract infection 4 Rubella
4
The primary safety issue related to the presence of a taste deficit in a young child is there will most likely be: 1 Little incentive to hydrate 2 No social connection to food 3 Limited food experimentation 4 Little discretion for ill-tasting substances
4
With advancing age, which of the following normal physiological changes in sensory function occurs? 1 Decreased sensitivity to glare 2 Increased number of taste buds 3 Difficulty discriminating vowel sounds 4 Decreased sensitivity to pain
4
The nurse is teaching about signs and symptoms of cataracts. Which change would the nurse emphasize as possibly indicating beginning cataract formation? Diplopia Cloudy pupil Loss of peripheral vision Blurred vision
d
The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the nurse's priority action? Notify the physician. Document the finding in the records. Recheck the reflex after several hours. Monitor the eye movements and pupil reactions closely.
a
The nurse is teaching a group of older adults about basic eye examinations. What would the nurse recommend about the frequency for eye examinations for most people over 65 years of age? Every 1 to 2 years Every 2 to 4 years Every 3 to 5 years When the primary health care provider recommends
a
What is the major consideration when selecting toys for a child who is cognitively impaired? Safety Age appropriateness Ability to provide exercise Ability to teach useful skills
a
What term is used to identify the most common type of hearing loss, which results from interference of transmission of sound to the middle ear? Conductive Sensorineural Mixed conductive-sensorineural Central auditory imperceptive
a
When should a child diagnosed with cognitive impairment be referred for stimulation and educational programs? As young as possible. As soon as they have the ability to communicate in some way. At age 3 years, when schools are required to provide services. At age 5 or 6 years, when schools are required to provide services.
a
Which action best facilitates lipreading by the hearing-impaired child? Speaking at an even rate Exaggerating pronunciation of words Avoiding using facial expressions Repeating in exactly the same way if child does not understand
a
A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents? "Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide." "The drug keeps your baby from requiring too much sedation." "Surfactant is used to reduce episodes of periodic apnea." "Your baby needs this medication to fight a possible respiratory tract infection."
a
An older adult in the family practice clinic reports a decrease in hearing in one ear for over a week. What action by the nurse is most appropriate? Assess for cerumen buildup. Facilitate audiological testing. Perform tuning fork tests. Review the medication list.
a
In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect: hypovolemia and/or shock. a nonneutral thermal environment. central nervous system injury. pending renal failure.
a
A client had a myringotomy. What would the nurse include as part of discharge teaching? Buy dry shampoo to use for a week. Drink liquids through a straw. Flying is not allowed for 1 month. Hot water showers will help the pain.
a
A client has a foreign body in one eye. What action by the nurse is appropriate for the client's care? Administering ordered antibiotics Assessing the patient's visual acuity Obtaining consent for enucleation Removing the object immediately
a
A client has mastoiditis and is prescribed antibiotics. What health teaching by the nurse is most important for this client? "Immediately report headache or stiff neck." "Keep all follow-up appointments." "Take the antibiotics with a full glass of water." "Take the antibiotic on an empty stomach."
a
A client is scheduled to have a tumor of the middle ear removed. Which perioperative health teaching is most important for the nurse to include? Expecting hearing loss in the affected ear Managing postoperative pain Maintaining NPO status prior to surgery Understanding which medications are allowed the day of surgery
a
A client presents to the emergency department reporting a foreign body in the eye. For what diagnostic testing would the nurse prepare the client? Corneal staining Fluorescein angiography Ophthalmoscopy Tonometry
a
A nurse is teaching a client about ear hygiene and health. Which statement by the client indicates a need for further teaching? "A soft cotton swab is alright to clean my ears with." "I make sure my ears are dry after I go swimming." "I use good earplugs when I practice with the band." "Keeping my diabetes under control helps my hearing."
a
A nurse is teaching a community group about preventing hearing loss. What instruction is appropriate? "Always wear a bicycle helmet." "Avoid swimming in ponds or lakes." "Don't attend fireworks shows." "Use a cerumen spoon to clean ears."
a
A nurse would suspect possible visual impairment in a child who displays: excessive rubbing of the eyes. rapid lateral movement of the eyes. delay in speech development. lack of interest in casual conversation with peers.
a
Prevention of hearing impairment in children is a major goal for the nurse. How can this be best achieved? Being involved in immunization clinics for children. Assessing a newborn for hearing loss. Answering parents' questions about hearing aids. Participating in hearing screening in the community.
a
The nurse is assessing a client admitted to the emergency department with possible retinal detachment. What assessment findings would the nurse expect? (Select all that apply.) Presence of bright light flashes Decreased visual field in affected eye Feeling like a curtain is over one eye Gradual changes in visual acuity Painful throbbing in the affected eye
a, b, c
The nurse is teaching a client about care after surgery to repair a retinal detachment. What health teaching would the nurse include? (Select all that apply.) "Report sudden pain in the surgical eye." "Report if the surgical eye remains dilated." "Avoid close vision activities in the first week." "Avoid activities that increase intraocular pressure." "Report sudden reduced visual acuity."
a, b, c, d, e
The nurse is teaching a client about postoperative care after a LASIK procedure. Which common complications/adverse effects could occur either immediately or later after this type of surgery? (Select all that apply.) Halos around lights Blurred vision Blindness Infection Dry eyes
a, b, d, e
The nurse teaches assistive personnel about age-related changes that affect the eyes and vision. Which changes would the nurse include? (Select all that apply.) Decreased eye muscle tone Development of arcus senilis Increase in far point of near vision Decrease in general color perception Increase in point of near vision
a, b, d, e
Infants born between 34 0/7 and 36 6/7 weeks of gestation are called late-preterm infants because they have many needs similar to those of preterm infants. Because they are more stable than early-preterm infants, they may receive care that is much like that of a full-term baby. The mother-baby or nursery nurse knows that these babies are at increased risk for: (Select all that apply.) problems with thermoregulation. cardiac distress. hyperbilirubinemia. sepsis. hyperglycemia.
a, c, d
A client has a hearing aid. What care instructions does the nurse provide the assistive personnel (AP) in the care of this client? (Select all that apply.) "Be careful not to drop the hearing aid when handling." "Soak the hearing aid in hot water for 20 minutes." "Turn the hearing aid off when the client goes to bed." "Use a toothpick to clean debris from the device." "Wash the device with soap and a small amount of warm water." "Avoid using hair or cosmetic products near the hearing aid."
a, c, d, f
The nurse is teaching a group of adults about ways to prevent early cataract formation. What health teaching would the nurse include? (Select all that apply.) "Wear eye and head protection when playing sports." "Be sure to get 7 to 8 hours of sleep each night." "Drink less carbonated beverages, especially those with caffeine." "Wear sunglasses when going outdoors or in ultraviolet light." "Increase consumption of high-protein, low-carbohydrate foods." "Avoid smoking or participate in a smoking cessation program."
a, d, f
The nurse is teaching a client and family regarding symptoms to report to the primary health care provider after cataract surgery. Which symptoms would the nurse include in the teaching? (Select all that apply.) Sharp sudden pain in the surgical eye Green or yellow discharge from the surgical eye Eyelid swelling of the surgical eye Decreased vision in the surgical eye Blindness in the surgical eye Flashes or floaters seen in the surgical eye
all of them
The nurse is caring for a client after ear surgery. What health teaching instruction(s) would the nurse provide for this client to promote healing? (Select all that apply.) "Avoid straining when having a bowel movement." "Avoid drinking through a straw for 2 to 3 weeks." "Avoid air travel for 2 to 3 weeks after surgery." "Avoid crowds and people with infection, especially respiratory infection." "Avoid moving your head quickly, jumping, or bending over for 2 to 3 weeks." "Blow your nose very gently without blocking either nostril and keep your mouth open."
all of them
The nurse is teaching a family member who is caring for a client who is hearing impaired. What health teaching would the nurse include about communicating with the client? (Select all that apply.) "Make sure that the room is well lighted." "Speak slowly and clearly." "Do not shout but you may need to speak loudly." "Have conversations in a quiet room with minimal noise." "Get the client's attention before you begin to speak." "Move closer to the better hearing ear if possible."
all of them
A 26-year-old pregnant woman, gravida 2, para 1-0-0-1 is 28 weeks pregnant when she experiences bright red, painless vaginal bleeding. On her arrival at the hospital, what would be an expected diagnostic procedure? Amniocentesis for fetal lung maturity Ultrasound for placental location Contraction stress test (CST) Internal fetal monitoring
b
A 9 year old diagnosed with Down syndrome is mainstreamed into a regular third-grade class for part of the school day. His mother asks the school nurse about programs such as Cub Scouts that he might join. The nurse's recommendation should be based on what knowledge? Programs such as Cub Scouts are inappropriate for children who are cognitively impaired. Children with Down syndrome have the same need for socialization as other children. Children with Down syndrome socialize better with children who have similar disabilities. Parents of children with Down syndrome encourage programs such as scouting because they deny that their children have disabilities.
b
A client has been prescribed brinzolamide for glaucoma. What assessment by the nurse requires communication with the primary health care provider? Allergy to eggs Allergy to sulfonamides Use of contact lenses Use of beta blockers
b
A client is brought to the emergency department after a car crash. The client has a large piece of glass in the left eye. What action by the nurse takes priority? Administer a tetanus booster shot. Ensure that the client has a patent airway. Prepare to irrigate the client's eye. Turn the client on the unaffected side.
b
A newborn assessment shows separated sagittal suture, oblique palpebral fissures, depressed nasal bridge, protruding tongue, and transverse palmar creases. These findings are most suggestive of: microcephaly. Down syndrome. cerebral palsy. fragile X syndrome.
b
A nurse is providing a parent information regarding autism spectrum disorder (ASD). Which statement made by the parent indicates understanding of the teaching? "Autism is characterized by periods of remission and exacerbation." "The onset of autism usually occurs before toddler stage." "Children with autism have imitation and gesturing skills." "Autism can be treated effectively with medication."
b
A parent asks the nurse why a developmental assessment is being conducted for a child during a routine well-child visit. The nurse answers based on what knowledge about such routine developmental assessments? Not necessary unless the parents request them. The best method for early detection of cognitive disorders. Frightening to parents and children and should be avoided. Valuable in measuring intelligence in children.
b
A parent whose child has been diagnosed with a cognitive deficit should be counseled about what fact related to intellectual impairment? Is usually due to a genetic defect. Is likely caused by a variety of factors. Is rarely due to first-trimester events. Is usually caused by parental intellectual impairment.
b
An implanted ear prosthesis for children with sensorineural hearing loss is a(n): a. hearing aid. b. cochlear implant. c. auditory implant. d. amplification device.
b
Distortion of sound and problems in discrimination are characteristic of which type of hearing loss? Conductive Sensorineural Mixed conductive-sensorineural Central auditory imperceptive
b
During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient's wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure? Tympanoplasty Irrigation of the ear Pure tone test Otoscopic exam by a specialist
b
In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level? Necrotizing enterocolitis (NEC) Retinopathy of prematurity (ROP) Bronchopulmonary dysplasia (BPD) Intraventricular hemorrhage (IVH)
b
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa. The signs of NEC are nonspecific. Some generalized signs include: hypertonia, tachycardia, and metabolic alkalosis. abdominal distention, temperature instability, and grossly bloody stools. hypertension, absence of apnea, and ruddy skin color. scaphoid abdomen, no residual with feedings, and increased urinary output.
b
The most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is: bleeding. intense abdominal pain. uterine activity. cramping.
b
The nurse is assessing a client's medication profile to determine risk for tinnitus. Which drug classification is most likely to cause this health problem? Cephalosporins NSAIDs Beta-adrenergic blockers Osmotic diuretics
b
The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction? "I will take my child to the audiologist because he doesn't seem to hear me except when I look directly at him." "Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle." "Making my child wear ear plugs when she goes to a rock concert may save her hearing!" "I see now why when my child has a cold, he complains about everything tasting blah!"
b
The nurse is teaching a client about factors that can cause external otitis. Which of these factors would the nurse emphasize as the highest risk? Excess cerumen Swimming Sinus congestion Meniere disease
b
The school nurse is caring. What emergency treatment is appropriate for a child with a penetrating eye injury? Applying a regular eye patch. Applying a Fox shield to the affected eye and any type of patch to the other eye. Applying ice until the physician is seen. Irrigating the eye copiously with a sterile saline solution.
b
Which intervention is focused on facilitating socialization of the cognitively impaired child? Provide age-appropriate toys and play activities. Provide peer experiences such as Special Olympics when older. Avoid exposure to strangers who may not understand cognitive development. Emphasize mastery of physical skills because they are delayed more often than verbal skills.
b
Which maternal condition always necessitates delivery by cesarean section? Partial abruptio placentae Total placenta previa Ectopic pregnancy Eclampsia
b
health teaching is most important for the nurse to include? "Avoid reading, writing, or close work such as sewing." "Report immediate loss of vision of pain in the affected eye." "Keep the follow-up appointment with the ophthalmologist." "Remove your eye patch every hour for eyedrops."
b
A hospitalized client has a new diagnosis of Ménière disease. What would the nurse include in health teaching to reduce symptoms for this disorder? (Select all that apply.) "Apply heat to the ear for 20 minutes three times a day." "Move the head slowly to prevent worsening of the vertigo." "Avoid food additives such as monosodium glutamate (MSG)." "Quit smoking to increase blood flow to the inner ear." "Avoid caffeinated beverages." "Avoid standing on chairs, step stools, or ladders."
b, c, d, e, f
The nurse is teaching a client about preventing intraocular pressure increase after cataract surgery. Which health teaching would the nurse include? (Select all that apply.) "Don't lift objects weighing more than 20 lb (9.1 kg)." "Avoid blowing your nose or sneezing." "Don't bend down from the waist." "Don't strain to have a bowel movement." "Avoid having sexual intercourse." "Don't wear tight shirt or blouse collars."
b, c, d, e, f
Which interventions should the nurse plan when caring for a child with a visual impairment? (Select all that apply.) Touch the child upon entering the room before speaking. Keep items in the room in the same location. Describe the placement of the eating utensils on the meal tray. Use color examples to describe something to a child who has been blind since birth. Identify noises for the child.
b, c, e
A client who is nearly blind is admitted to the hospital. What action by the nurse is most important? Allow the client to feel his or her way around. Let the client arrange objects on the bedside table. Orient the client to the room using a focal point. Speak loudly and slowing when talking to the client.
c
A client with Ménière disease is in the hospital when the client has an episode of this disorder. What action by the nurse is appropriate? Assess vital signs every 15 minutes. Dim or turn off lights in the client's room. Place the client in bed with the upper side rails up. Provide a cool, wet cloth for the client's face.
c
A client has external otitis. About what comfort measure would the nurse instruct the client? Applying ice four times a day Instilling vinegar-and-water drops Use of a heating pad to the ear Using a home humidifier
c
A client has severe tinnitus that has not responded to treatment. What action by the nurse is appropriate? Advise the client to take antianxiety medication. Educate the client on nerve-cutting procedures. Refer the client to online or local support groups. Refer the client to a mental health professional.
c
A client is scheduled for a tympanoplasty. What action(s) by the nurse are (is) most appropriate? (Select all that apply.) Administer preoperative opioids. Assess for allergies to local anesthetics. Ensure that informed consent is on the health record. Give prescribed antivertigo medications. Teach that hearing improves immediately.
c
A client with a family history of glaucoma asks the nurse how to prevent glaucoma? What statement by the nurse is appropriate? "You should check with your primary health care provider about eye examination." "You should have genetic testing to determine your risk for glaucoma." "You should have your intraocular pressure measured once or twice a year." "You should check with your primary health care provider about preventive drug therapy."
c
A client's intraocular pressure (IOP) is 28 mm Hg. What action would the nurse anticipate? Educate the client on corneal transplantation. Facilitate scheduling the eye surgery. Teach about drugs for glaucoma. Refer the patient to local Braille classes.
c
An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following? "I will make sure that dad always wears warm socks." "Dad needs to wear his glasses so he can delay the onset of macular degeneration." "I will ask the home health aide to carefully inspect dad's feet every day when she helps him bathe." "We will give him only warm foods, so that he doesn't burn his mouth."
c
An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: birth injury. hypocalcemia. hypoglycemia. seizures.
c
Infants of mothers with diabetes (IDMs) are at higher risk for developing: anemia. hyponatremia. respiratory distress syndrome. sepsis.
c
The child diagnosed with Down syndrome should be evaluated for which characteristic before participating in some sports? Hyperflexibility Cutis marmorata Atlantoaxial instability Speckling of iris (Brushfield's spots)
c
The client's electronic health record indicates a sensorineural hearing loss. What assessment question does the nurse ask to determine the possible cause? "Do you feel like something is in your ear?" "Do you have frequent ear infections?" "Have you been exposed to loud noises?" "Have you been told your ear bones don't move?"
c
The nurse is discussing sexuality with the parents of an adolescent with moderate cognitive impairment. Which should the nurse consider when dealing with this issue? Sterilization is recommended for any adolescent with cognitive impairment. Sexual drive and interest are limited in individuals with cognitive impairment. Individuals with cognitive impairment need a well-defined, concrete code of sexual conduct. Sexual intercourse rarely occurs unless the individual with cognitive impairment is sexually abused.
c
The nurse is talking with a 10 year old who wears bilateral hearing aids. The left hearing aid is making an annoying whistling sound that the child cannot hear. What is the most appropriate nursing action to address this issue? Ignore the sound. Ask the child to reverse the hearing aids. Suggest that the child reinsert the hearing aid. Suggest that the child raise the volume of the hearing aid.
c
The nurse is teaching a client about cataract surgery. Which statement would the nurse include as part of preoperative preparation? "You will receive general anesthesia for the surgical procedure." "You will be in the hospital for only 1 to 2 days if everything goes as expected." "You will need to put several types of eyedrops in your eyes before and after surgery." "You will be on bedrest for about a week after the surgical procedure."
c
The nurse is teaching new assistive personnel (AP) about caring for older adults. Which statement would the nurse include about hearing ability of this client group? "You need to talk very loudly when communicating with these clients." "You always need to check each client's ears for excess ear wax." "Remember to face the client when talking with him or her." "Assess each client's hearing ability using the voice or whisper test."
c
The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse's best action to provide recreational activities during the rehabilitation phase? Place the television to the left or right of patient's visual field. Encourage the patient to learn braille. Suggest use of talking books. Provide headphones for listening to music.
c
What should the nurse keep in mind when planning to communicate with a child who is diagnosed with an autism spectrum disorder (ASD)? The child has normal verbal communication. The child is expected to use sign language. The child may exhibit monotone speech and echolalia. The child is not listening if he/she is not looking at the nurse.
c
Which action is contraindicated when a child diagnosed with Down syndrome is hospitalized? Determine the child's vocabulary for specific body functions. Assess the child's hearing and visual capabilities. Encourage parents to leave the child alone at night. Have meals served at the child's usual mealtimes.
c
Which condition indicates concealed hemorrhage when the patient experiences an abruptio placentae? Decrease in abdominal pain Bradycardia Hard, board-like abdomen Decrease in fundal height
c
Which is the most common congenital anomaly associated with Down syndrome? Hypospadias Pyloric stenosis Septal defects Congenital hip dysplasia
c
Which statement accurately describes fragile X syndrome? It is a chromosome defect affecting only females. It is a chromosome defect that follows the pattern of X-linked recessive disorders. It is the second most common genetic cause of cognitive impairment. It is the most common cause of noninherited cognitive impairment.
c
Which statement by a parent about a child's conjunctivitis indicates that further teaching is needed? "I'll have separate towels and washcloths for each family member." "I'll notify my doctor if the eye gets redder or the drainage increases." "When the eye drainage improves, we'll stop giving the antibiotic ointment." "After taking the antibiotic for 24 hours, my child can return to school."
c
Which teaching guideline helps prevent eye injuries during sports and play activities? Restrict helmet use to those who wear eyeglasses or contact lenses. Discourage the use of goggles with helmets. Wear eye protection when participating in high risk sports such as paintball.
c
The nurse assesses a toddler for excessive tearing and corneal haziness to confirm which medical diagnosis? Viral conjunctivitis Paralytic strabismus Congenital cataract Infantile glaucoma
d
A 75-year-old woman walks into the emergency department with complaints of "not feeling well." Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings? Normal in the older adult A need for the patient to be evaluated for cognitive impairment A side effect of anti-hypertensive medication Pathologic impairment of sensory responses
d
A client is taking timolol eyedrops. The nurse assesses the client's pulse at 48 beats/min. What action by the nurse is the priority? Ask the client about excessive salivation. Take the client's blood pressure and temperature. Give the drops using punctal occlusion. Hold the eyedrops and notify the primary health care provider.
d
A client who has had cold symptoms for a week visits the local urgent care center with report of left ear discomfort, dizziness, and decreased hearing. What additional assessment findings would the nurse expect? High fever Nausea and vomiting Elevated blood pressure Purulent ear drainage
d
A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 lbs, 6 ounces). The nurse's most appropriate action is to: leave the infant in the room with the mother. take the infant immediately to the nursery. perform a gestational age assessment to determine whether the infant is large for gestational age. monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
d
A nurse is preparing a teaching session for parents on the prevention of childhood hearing loss. The nurse identify what as being the most common cause of hearing impairment in children? Auditory nerve damage Congenital ear defects Congenital rubella Chronic otitis media
d
A nurse is seeing clients in the ophthalmology clinic. Which client would the nurse see first? Client with intraocular pressure reading of 24 mm Hg Client with a tearing, reddened eye with exudate Client whose red reflex is absent on ophthalmologic examination Client who has had cataract surgery and has worsening vision
d
A nurse is teaching a community group about noise-induced hearing loss. Which client who does not use ear protection would the nurse refer to an audiologist as the priority? Client with an hour car commutes on the freeway each day. Client who rides a motorcycle to work 20 minutes each way. Client who sat in the back row at a rock concert recently. Client who is a tree-trimmer and uses a chainsaw 6 to 7 hours a day.
d
A placenta previa in which the placental edge just reaches the internal os is more commonly known as: a. total. b. partial. c. complete. d. marginal.
d
An adolescent male visits his primary care provider complaining of difficulty with his vision. When the nurse asks the adolescent to explain what visual deficits he/she is experiencing, the adolescent states, "I am having difficulty seeing distant objects; they are less clear than things that are close." What disorder does the nurse suspect the adolescent has? a. Hyphema b. Astigmatism c. Amblyopia d. Myopia
d
An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response? "Your wife should increase the spices in your food, as the pneumonia changes your sense of smell" "Notify your doctor immediately, because this is a concerning reaction to the medication." "You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection." "You should see an improvement in the next week or so. Call if this continues."
d
Because of the premature infant's decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant? Delayed growth and development Ineffective thermoregulation Ineffective infant feeding pattern Risk for infection
d
Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are: suffering from sleep or wakeful apnea. experiencing severe swings in blood pressure. trying to maintain a neutral thermal environment. breathing in a respiratory pattern common to premature infants.
d
The nurse assesses a client for factors that place the client at risk for cataracts. Which factor places the client at the highest risk for cataract development? Heart disease Glaucoma Diabetes mellitus Advanced age
d
The nurse is teaching an older adult how to prevent buildup of ear wax. Which statement by the nurse is most appropriate? "Visit your primary health care provider each month for wax removal." "Drink plenty of water and other liquids to prevent hardening of the ear wax." "Irrigate each ear once a month to remove wax and prevent was buildup." "Put one drop of mineral oil in each ear once a week at bedtime."
d
The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements? "This will help us to identify your baby's risk for ear infections the first year of life." "Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother." "Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child." "Imitation of sounds is the first step in language development, and it is important to identify alterations early."
d
The teaching plan for the parents of a 3-year-old child with amblyopia should include which instruction? Apply a patch to the child's eyeglass lenses. Apply a patch only during waking hours. Apply a patch over the "bad" eye to strengthen it. Cover the "good" eye completely with a patch.
d
What intervention should the nurse implement when noting gross bleeding in a child's eye after being hit in the eye? Apply a Fox shield. Instruct the adolescent to apply ice for 24 hours. Have adolescent rest with eye closed and heat applied. Notify parents that adolescent needs to see an ophthalmologist.
d
When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has: few blood vessels visible through the skin. more subcutaneous fat. well-developed flexor muscles. greater surface area in proportion to weight.
d
When providing an infant with a gavage feeding, which of the following should be documented each time? The infant's abdominal circumference after the feeding. The infant's heart rate and respirations. The infant's suck and swallow coordination. The infant's response to the feeding.
d