Sensory Perception MASTERY ASSESSMENT

A client has been receiving digoxin. The client calls the clinic and complains of "yellow vision." What is the nurse's best response? 1-"This is related to your illness rather than to your medication." 2-"Take the medication because this is not a serious side effect." 3-"This side effect is only temporary. You should continue the medication." 4-"The medication may need to be discontinued. Come to the clinic this afternoon."

"The medication may need to be discontinued. Come to the clinic this afternoon."--Yellow vision indicates digoxin toxicity; the medication should be withheld until the healthcare provider can assess the client and check the digoxin blood level. Yellow vision is related to digoxin therapy, not the client's underlying medical condition. Yellow vision is a sign of digoxin toxicity; taking more digoxin will escalate the digoxin toxicity.

The nurse is assessing a 5-year-old child using the Glasgow Coma Scale after surgery. What rating should the nurse assign if the child shows a confused verbal response? 1-1 2-2 3-3 4-4

4--According to the Glasgow Coma Scale, a confused verbal response indicates a score of 4. When the child gives no response, the score is a 1. If the child makes incomprehensible sounds, then the score is a 2. When the child speaks inappropriate words, then the score is a 3.

A nurse is teaching a client with a diagnosis of open-angle glaucoma. The nurse explains that the chief aim of treatment is to meet which goal? 1-Rest the eye. 2-Dilate the pupil. 3-Prevent secondary infections. 4-Control the intraocular pressure.

Control the intraocular pressure--Individuals with glaucoma have increased intraocular pressure that must be returned to the expected range, or blindness will result. Resting has no effect on this condition because it will not decrease the pressure. Dilation of the pupils may increase the pressure further by obstructing flow; increased pressure reduces the visual field and leads to blindness. Glaucoma does not lead to secondary infections.

Following a motor vehicle accident a client reports seeing frequent flashes of light. Which condition should the nurse be prepared to address? 1-Glaucoma 2-Scleroderma 3-Detached retina 4-Cerebral concussion

Detached retina--The detached retina is caused by vitreous traction on the retina. Glaucoma causes the individual to see halos around lights. Scleroderma is a disease of the connective tissue, not the eye. Cerebral concussions do not result in this ocular symptom.

The mother of a 2-year-old child tells the nurse that she is concerned about her child's vision. What behavior when the child is tired leads the nurse to suspect strabismus? 1-One eyelid droops. 2-Both eyes look cloudy. 3-One eye moves inward. 4-Both eyes blink excessively.

One eye moves inward--An inward moving eye (tropia) is one form of strabismus. A drooping eyelid is called ptosis; it may be congenital or caused by trauma. Cloudy eyes are associated with congenital cataracts. Blinking may be a tic.

A client with the diagnosis of multiple sclerosis experiences a sudden loss of vision and asks the nurse what caused it to happen. The nurse considers the common clinical findings associated with multiple sclerosis before responding. Which is the most probable cause of the client's sudden loss of vision? 1-Virus-induced iritis 2-Intracranial pressure 3-Closed-angle glaucoma 4-Optic nerve inflammation

Optic nerve inflammation--Optic nerve inflammation is a common early effect of multiple sclerosis caused by lesions in the optic nerves or their connections (demyelization). This effect may resolve during periods of remission. At present there is no evidence of viral infection of the eyes in multiple sclerosis. Tumors of the brain and cerebral edema, not multiple sclerosis, cause increased intracranial pressure because the skull cannot expand. Closed-angle glaucoma causes blindness as a result of increased intraocular pressure, not inflammation of the optic nerve, which is commonly associated with multiple sclerosis. Closed-angle glaucoma is unrelated to multiple sclerosis.

The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections? 1-Immunologic differences between adults and young children 2-Structural differences between eustachian tubes of younger and older children 3-Functional differences between eustachian tubes of younger and older children 4-Circumference differences between middle ear cavity size of adults and young children

Structural differences between eustachian tubes of younger and older children--The eustachian tube in young children is shorter and wider, allowing a reflux of nasopharyngeal secretions. Immunologic differences are not a factor in the development of otitis media. There is no difference in the function of the eustachian tube among age groups. The size of the middle ear does not play a role in the occurrence of otitis media in young children.

While assessing the pupils of a client, a healthcare professional notices pupillary dilatation. Which drug intake might have resulted in this condition? 1-Cocaine 2-Atropine 3-Morphine 4-Pilocarpine

atropine--The intake of eye medications such as atropine will cause dilatation of the pupils. Cocaine, morphine, and pilocarpine cause pupillary constriction.

What is a common characteristic of Sjögren's syndrome (SS)? 1-Dry eyes 2-Muscle cramping 3-Urinary tract infection 4-Elevated blood pressure

dry eyes--Sjögren's syndrome (SS) is a group of problems that often appear with other autoimmune disorders. Problems include dry eyes, which are caused by autoimmune destruction of the lacrimal glands. Muscle cramping, urinary tract infection, and elevated blood pressure are not common characteristics of Sjögren's syndrome (SS).

Which condition is characterized with an involuntary and rapid twitching of the client's eyeball? 1-Ptosis 2-Anisocoria 3-Nystagmus 4-Enophthalmos

nystagmus--Nystagmus is characterized by an involuntary and rapid twitching of the eyeball. Ptosis is characterized by drooping of eyelids. Anisocoria is characterized by a normally noticeable difference in the size of the pupils and is a normal finding in 5% of the population. Enophthalmos is characterized by the sunken appearance of the eye.