Sensory Perception EAQ

The nurse notes that a 6-month-old infant is startled by a loud noise but does not turn in the direction of the sound. How should the nurse interpret this response? 1 As evidence of hearing loss 2 As an effect of vision deficits 3 As developmentally appropriate 4 As evidence of a low-normal hearing range

1 As evidence of hearing loss By 3 to 4 months of age an infant should localize sound by looking in the direction of the sound. The nurse's observation does not provide information about the infant's ability to see. Low-normal hearing range is not within the norm for this age group. This response indicates that that the infant's hearing is not developmentally appropriate.

Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? 1 Constant blurring 2 Abrupt attacks of acute pain 3 Sudden, complete loss of vision 4 Impairment of peripheral vision

4 Impairment of peripheral vision Open-angle glaucoma has an insidious onset, with increased intraocular pressure on the retina and blood vessels in the eye. Peripheral vision is decreased as the visual field progressively diminishes. Constant blurring may occur with untreated acute angle-closure glaucoma. Pain occurs in acute angle-closure, not open-angle, glaucoma. Occlusions of the central retinal artery or retinal detachment will cause a sudden loss of vision.

A nurse suspects that a 7-month-old infant who is brought to the well-baby clinic for the first time has a hearing deficit. What behavior leads the nurse to come to this conclusion? 1 The infant does not always turn the head when called by name. 2 The mother says that the infant is unable to learn the word "mama." 3 The infant fails to demonstrate the Moro reflex in response to hand clapping. 4 The mother says the infant stopped making verbal sounds about a month ago.

4 The mother says the infant stopped making verbal sounds about a month ago. Deaf infants commonly babble until they are about 6 months old but then stop because their vocalizations are not reinforced with hearing. Learning to say one word starts at about 11 to 12 months of age. Infants with no hearing impairment do not respond to their names all the time. The Moro reflex is not expected at 7 months; it usually disappears when the infant is 3 to 4 months old.

A nurse is caring for a client after a thyroidectomy. Because of concerns about potential nerve injury associated with this type of surgery, the nurse should assess for which functional ability? 1 Speaking 2 Swallowing 3 Pursing the lips 4 Turning the head

1 Speaking The laryngeal nerve is close to the operative site and may be damaged inadvertently. Loss of the gag reflex occurs with general anesthesia; the ability to swallow signifies its return. Pursing the lips assesses the seventh cranial (facial) nerve, which is not affected by thyroid surgery. Muscles and nerves involved in turning the head are not near the thyroid gland.

A 2-year-old toddler has hearing loss caused by recurrent otitis media. What treatment does the nurse anticipate that the practitioner will recommend? 1 Ear drops 2 Myringotomy 3 Mastoidectomy 4 Steroid therapy

2 Myringotomy Myringotomy is a surgical opening into the eardrum to permit drainage of accumulated fluid associated with otitis media. Ear drops are not used because they will obscure the view of the tympanic membrane. Removal of the mastoid will not relieve pressure within inflamed ears. Antibiotics, not steroids, are used for an infectious process.

A client is admitted with a brain attack (CVA) with left-sided paralysis. The client leans to the left when placed in a sitting position and fails to respond to stimuli in the left visual field. The client's plan of care should include: 1 Keeping the client's head turned to the right 2 Approaching the client from the left side 3 Teaching the client to use head movements to scan the left field of vision 4 Arranging the furniture in the client's room so that the door is in the right visual field

3 Teaching the client to use head movements to scan the left field of vision The client should be encouraged to make a conscious attempt to turn the head to the left so that the remaining vision can be used to scan the environment and to compensate for the vision lost in the left visual field. Keeping the head turned to the right increases the amount of the environment that cannot be seen in the left visual field; the head should be turned to the left. The client should be approached from the right side because the left visual field is impaired. Although it may help to arrange furniture so that the door is in the client's right visual field, it is inadequate for safety; the client must be taught to scan the left visual field by turning the head to the left.

fter a client has spinal surgery, it is essential that the nurse: 1 Encourage the client to drink fluids 2 Log-roll the client to the prone position 3 Assess the client's feet for circulation and sensation 4 Observe the client's bowel movements and voiding patterns

Assess the client's feet for circulation and sensation Alteration in circulation and sensation indicates damage to the spinal cord; if this occurs, the health care provider must be notified immediately. After surgery, the health care provider's prescription should specify if the client is permitted oral fluids. The prone position is contraindicated because it will hyperextend the vertebral column; log-rolling from side to side is preferred. Although observing the client's bowel movements and voiding patterns will be done, it is not the priority.

A child visits the pediatric clinic for a 6-week checkup after an adenoidectomy. The nurse should evaluate the child's ability to: 1 Hear 2 Swallow 3 Speak clearly 4 Cough voluntarily

1 Hear Residual edema may interfere with hearing; further treatment may be necessary. The surgical site should be healed and not cause discomfort when swallowing. Speech should not be affected, because the vocal cords are not within the operative area. The ability to cough is not affected before or after surgery.

The nurse considers that sensory restriction in a client who is blind can: 1 Increase the use of daydreaming and fantasy 2 Heighten the client's ability to make decisions 3 Decrease the client's restlessness and lethargy 4 Lead to the use of permanent neurotic behaviors

1 Increase the use of daydreaming and fantasy Internal self-stimulation increases as external stimuli decrease. Blindness is an added stress that can increase anxiety, which impairs decision-making; lack of visual stimuli limits data for decision-making. Lack of visual stimuli can increase restlessness, lethargy, and apathy. Blindness will not precipitate neurotic behavior unless other emotional factors are present.

A nurse is caring for a client with glaucoma. What rationale associated with the need for treatment of this condition should the nurse include in a teaching program? 1 Total blindness is inevitable 2 Lost vision cannot be restored 3 Use of both eyes usually is restricted 4 Surgery will help the problem only temporarily

2 Lost vision cannot be restored Retinal damage caused by the increased intraocular pressure of glaucoma is progressive and permanent if the disease is not controlled. Early treatment may prevent blindness. One eye may be affected, and there is no restriction on the use of either eye. Surgery can open up drainage and permanently reduce pressure.

A client with diabetes mellitus complains of difficulty seeing. The nurse concludes that the causative factor is: 1 Lack of glucose in the retina 2 Neovascularization of the retina 3 Inadequate glucose supply to rods and cones 4 Destructive effect of ketones on retinal metabolism

2 Neovascularization of the retina With diabetes mellitus, proliferation of fragile vessels and progressive thickening of the capillary basement membranes lead to decreased retinal perfusion and hemorrhages in the eye. Hemorrhages in the eyes precipitate retinal detachment, resulting in blindness. There is an increase in serum glucose in clients with diabetes mellitus; thickening of the capillary basement membranes can occur, even if the glucose level is maintained within normal limits. Ketones do not affect retinal metabolism; retinopathy is a result of vascular changes, retinal detachment, and hemorrhage within the eye.

A nurse in the pediatric clinic observes an 11-month-old boy who is sitting on his mother's lap crying and tugging at his right ear. What probable problem does this behavior indicate? 1 Child abuse 2 Otitis media 3 Hearing impairment 4 Upper respiratory infection

2 Otitis media Young children who cannot verbalize the presence of pain use nonverbal behaviors to indicate discomfort; crying and tugging at a painful ear are typical behaviors of an infant with otitis media. There are no data to indicate child abuse. Tugging at the ear is not an indication that the child has a hearing problem. Tugging at the ear is specific to otitis media, not an upper respiratory infection.

A client with glaucoma asks a nurse about future treatment and precautions. What information should the nurse's explanation include? 1 Avoidance of cholinergics 2 Surgical replacement of lens 3 Continuation of therapy for life 4 Prevention of high blood pressure

3 Continuation of therapy for life Therapy must be continued for life to prevent damage to the optic nerve from increased intraocular pressure. Cholinergics are used in the treatment of glaucoma; anticholinergics are contraindicated. The surgical replacement of the lens is the treatment for cataracts. There is an increase in intraocular pressure with glaucoma; the blood pressure may be unaffected.

A nurse knows that children with attention deficit-hyperactivity disorder (ADHD) may be learning disabled. This means that these children: 1 Will probably not be self-directed learners 2 Have intellectual deficits that interfere with learning 3 Experience perceptual difficulties that interfere with learning 4 Are usually performing two grade levels below their age norm

3 Experience perceptual difficulties that interfere with learning ADHD interferes with the ability to perceive and respond to sensory stimuli, resulting in a deficit in interpreting new sensory data. This makes learning difficult. It is not true that children with ADHD have intellectual deficits that interfere with learning; there is no cognitive impairment present. It is not necessarily true that children with ADHD are not self-directed learners or that they perform two grade levels below their age norm.

When meeting the unique preoperative teaching needs of an older adult, the nurse plans a teaching program based on the principle that learning: 1 Reduces general anxiety 2 Is negatively affected by aging 3 Requires continued reinforcement 4 Necessitates readiness of the learner

3 Requires continued reinforcement Neurological aging causes forgetfulness and slower response time; repetition increases learning. The principle that learning reduces general anxiety is a general principle applicable to all learning. The older adult has no more difficulty learning than a younger person, although it may take longer. The principle that learning necessitates readiness of the learner is a general principle applicable to all learning.

A nurse is caring for a client with pulmonary tuberculosis who is to receive several antitubercular medications. Which of the first-line antitubercular medications is associated with damage to the eighth cranial nerve? 1 Isoniazid (INH) 2 Rifampin (Rifadin) 3 Streptomycin 4 Ethambutol (Myambutol)

3 Streptomycin Streptomycin is ototoxic and can cause damage to the eighth cranial nerve, resulting in deafness. Assessment for ringing or roaring in the ears, vertigo, and hearing acuity should be made before, during, and after treatment. Isoniazid does not affect the ear; however, blurred vision and optic neuritis, as well as peripheral neuropathy, may occur. Rifampin does not affect hearing; however, visual disturbances may occur. Ethambutol does not affect hearing; however, visual disturbances may occur.

A client has primary open-angle glaucoma. The nurse expects that the client will receive a prescription for which eye drops? 1 Tetracaine (Pontocaine) 2 Cyclopentolate (Cyclogyl) 3 Timolol maleate (Timoptic) 4 Atropine sulfate (Atropisol Ophthalmic)

3 Timolol maleate (Timoptic) Timolol maleate is a beta-adrenergic antagonist that decreases aqueous humor production and increases outflow, thereby reducing intraocular pressure. Tetracaine is a topical anesthetic; it will not reduce the increased intraocular pressure associated with glaucoma. Cyclopentolate is contraindicated because it dilates the pupil and paralyzes ciliary muscles. Atropine sulfate, a mydriatic, is contraindicated because it dilates the pupil, obstructing drainage, which increases intraocular pressure.

A client has been diagnosed as "brain dead". The nurse understands that this means that the client has: 1 no spontaneous reflexes. 2 shallow and slow breathing. 3 no cortical functioning with some reflex breathing. 4 deep tendon reflexes only and no independent breathing.

3 no cortical functioning with some reflex breathing. A client who is declared as being brain dead has no function of the cerebral cortex and a flat EEG. The client may have some spontaneous breathing and a heartbeat. The guidelines established by the American Association of Neurology include coma or unresponsiveness, absence of brainstem reflexes, and apnea. There are specific assessments to validate the findings. The other answer options do not fit the definition of "brain dead."

Which age-related change should the nurse consider when formulating a plan of care for an older adult? (Select all that apply.) 1 Difficulty in swallowing 2 Increased sensitivity to heat 3 Increased sensitivity to glare 4 Diminished sensation of pain 5 Heightened response to stimuli

3 Increased sensitivity to glare 4 Diminished sensation of pain Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare . Diminished sensation of pain may make an older individual unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older individuals. Older individuals tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in the older individual.

A client is scheduled for a labyrinthectomy to treat Ménière syndrome. What expected outcome of the procedure should be included in preoperative teaching? 1 Absence of pain 2 Decreased cerumen 3 Loss of sense of smell 4 Permanent irreversible deafness

4 Permanent irreversible deafness The labyrinth is the inner ear and consists of the vestibule, cochlea, semicircular canals, utricle, saccule, cochlear duct, and membranous semicircular canals. A labyrinthectomy is performed to alleviate the symptom of vertigo but results in deafness, because the organ of Corti and cochlear nerve are located in the inner ear. There is no pain associated with Ménière syndrome. Ménière syndrome is not related to cerumen production. The loss of the sense of smell (anosmia) is not affected by surgery to the ear.

An 80-year-old female is admitted to the hospital because of complications associated with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated because she is alert and able to care for herself. The nurse's best response is: 1 "The body's fluid needs decrease with age because of tissue changes." 2 "Access to fluid may be insufficient to meet the daily needs of the older adult." 3 "Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid." 4 "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased."

4 "The thirst reflex diminishes with age, and therefore the recognition of the need for fluid is decreased." For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement "The body's fluid needs decrease with age because of tissue changes." The statement "Access to fluid may be insufficient to meet the daily needs of the older adult" is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake.

A nurse encourages parents to have their toddler's eyes tested especially for monocular strabismus. What should the nurse explain may occur if the condition is not corrected early? 1 Dyslexia will develop. 2 Peripheral vision will disappear. 3 Vision in both eyes will be diminished. 4 Amblyopia will progress in the weak eye.

4 Amblyopia will progress in the weak eye. Amblyopia is reduced visual acuity that may occur when an eye weakened by strabismus is not forced to function. The lack of binocularity may result in impaired depth and spatial perception, not dyslexia. Depth and spatial perceptions are impaired when vision in one eye is severely impaired. Only vision in the affected eye will be diminished.

The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1 A physiological response to stress. 2 A conscious defense against anxiety. 3 An intentional attempt to gain attention. 4 An unconscious means of reducing stress.

4 An unconscious means of reducing stress. When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiological changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.

Which desired effect of therapy should the nurse explain to the client who has primary angle-closure glaucoma? 1 Dilating the pupil 2 Resting the eye muscles 3 Preventing secondary infection 4 Controlling intraocular pressure

4 Controlling intraocular pressure Glaucoma is a disease in which there is increased intraocular pressure resulting from narrowing of the aqueous outflow channel (canal of Schlemm). This can lead to blindness, caused by compression of the nutritive blood vessels supplying the rods and cones. Pupil dilation increases intraocular pressure because it narrows the canal of Schlemm. Intraocular pressure is not affected by activity of the eye. Although secondary infections are not desirable, the priority is to maintain vision by controlling the pressure.

When a client who had an above-the-knee amputation (AKA) complains of phantom limb sensations, the nursing staff should: 1 Reassure the client that these sensations will pass 2 Explain the psychological component involved to the client 3 Encourage the client to get involved in diversional activities 4 Describe the neurological mechanisms in language that the client understands

4 Describe the neurological mechanisms in language that the client understands Explanation of the underlying mechanism usually helps calm anxiety about a phantom pain experience. Reassuring the client that these sensations will pass is false reassurance because phantom limb sensations may not disappear. Explaining the psychological component involved to the client reinforces the idea that there is something psychologically wrong with the client. Encouraging the client to get involved in diversional activities may distract the client, but does not foster awareness of the cause.

A nurse is planning to screen a school-age child for impaired hearing because the child is receiving an antibiotic that affects hearing. Which medication does the nurse suspect may have caused hearing impairment? 1 Amoxicillin (Amoxil) 2 Ciprofloxacin (Cipro) 3 Clindamycin (Cleocin) 4 Gentamicin (Garamycin)

4 Gentamicin (Garamycin) Gentamicin (Garamycin) can be ototoxic because of its effects on the eighth cranial nerve. Reactions to amoxicillin (Amoxil) are usually allergic in nature. Impaired hearing does not occur with ciprofloxacin (Cipro) or with clindamycin (Cleocin).

A nurse is caring for a client who just has had surgery on the ear. The nurse should assess for what early indicator of potential damage to the motor branch of the facial nerve? 1 Pain behind the ear 2 Bitter, metallic taste 3 Dryness of the mouth 4 Inability to wrinkle the forehead

4 Inability to wrinkle the forehead The motor fibers of the facial nerve innervate the superficial muscles of the face and scalp. Pain behind the ear, a bitter, metallic taste, and dryness of the mouth are sensory responses that may be manifested when the injury is to the sensory, not motor, branch of the facial nerve.

A client who is legally blind is admitted to the hospital for surgery. What nursing action is most appropriate when caring for this client? 1 Enter the room while speaking softly 2 Touch the client gently before speaking 3 Hold the client by the elbow when ambulating 4 Keep the furniture in the same location in the room

4 Keep the furniture in the same location in the room Placing furniture and objects in the same location in the room promotes safety and independence. Entering a room while speaking softly can increase anxiety because the client may not be able to identify what is happening. Touching the client gently before speaking can startle the client and increase anxiety. The blind client should hold the nurse's elbow when ambulating.

A nurse obtains the nursing history from a client who has open-angle (chronic) glaucoma. The nurse anticipates that the client will report: 1 Flashes of light 2 Sensitivity to light 3 Seeing floating specks 4 Loss of peripheral vision

4 Loss of peripheral vision Increased intraocular pressure damages the optic nerve, interfering with peripheral vision. Flashes of light may be associated with a detached retina. There is difficulty in adjusting to darkness, not an intolerance to light. Seeing floating specks is not specific to glaucoma.