PrepU Questions: Week 15-- Sleep/Sensory & Pain

The nurse is caring for client prescribed morphine who is experiencing constipation. What intervention should the nurse recommend to the client? (Select all that apply.)

-Increased fluids -Increased fiber -Stool softener

The nurse is instructing a patient with Ménière's disease on dietary management to include as an adjunct to other more traditional therapies. The nurse would include which of the following? Select all that apply.

-Limit foods high in salt and sugar. -Avoid aspirin and aspirin products. -Avoid coffee, tea, and soft drinks.

Which of the following describes vertigo? Select all that apply.

-Misperception of motion -Spinning sensation -Objects are moving around him or her

Tinnitus is associated with which of the following hearing disorders? Select all that apply.

-Ménière's disease -Acoustic neuroma -Otosclerosis -Thyroid disease -Migraine headaches

Which nursing actions are performed according to guidelines for caring for clients with hearing impairments? Select all that apply

-Position yourself so that the light is on your face when you speak. -Demonstrate or pantomime ideas you wish to express. -Write down any ideas that you cannot convey to the person in another manner.

The nurse is caring for Jim, an 88-year-old nursing home resident who is suffering from sensory deprivation. He lives in a small room, has no visitors, and has few interests. The nurse performs which interventions to assist Jim in adapting to this sensory deficit? Select all that apply.

-Provide interactions with children and pets. -Encourage Jim to attend exercise classes. -Ensure that Jim eats at a table with other residents.

A client comes to the clinic for an ophthalmologic screening, which will include measurement of intraocular pressure (IOP) with a tonometer. Which statement about this procedure is true?

The tonometer will register the force required to indent or flatten the corneal apex.

Which statement describes benign paroxysmal positional vertigo (BPPV)?

The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired.

After cataract surgery the client's home environment may increase the risk for falls. Which nursing intervention should facilitate safety of the environment?

having a caregiver in the home for the first few days after surgery

A 60-year-old client tearfully explains to the nurse how her husband downplays her frequent migraines and tells her that she needs to "just push through a headache." She describes how her migraines have limited her ability to provide childcare for her young grandchildren and explains that she is unable to keep up her garden. The nurse should identify what nursing diagnosis when planning this client's care?

ineffective role performance related to migraine headaches

A client has just been told that he has lung cancer. The physician then describes several potential courses of treatment to the client. When the physician leaves the room, the client asks the nurse, "What did he just say?" The nurse understands that the client is experiencing:

sensory overload.

A client states to the nurse during a sleep assessment that it takes her more than 60 minutes to fall asleep. The nurse documents this time period as the client's:

sleep latency.

A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness?

somnolence

A client diagnosed with hypothyroidism is suffering from fatigue, lethargy, depression, and difficulty executing the tasks of everyday living. What type of sleep deprivation would the nurse suspect is affecting this client?

NREM deprivation

A client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?

"Don't fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days."

The nurse is educating an older adult client diagnosed with migraine headaches about the prescribed naproxen sodium for abortive therapy. Which statement made by the client establishes the need for further clarification?

"I can take up to 1200 mg in 24 hours because the package states this as the maximum dosage."

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

"I could use the TENS unit if I feel pain somewhere else on my body."

The nurse is encouraging a client to begin and maintain a sleep diary. What statement made by the client indicates an understanding of the purpose of the diary?

"I will record the time I go to bed and how long it takes me to fall asleep."

Which portion of the middle ear equalizes pressure?

Eustachian tube

Which conditions would occur due to the administration of an opioid antagonist in a client who is physically dependent on opioids?

withdrawal symptoms

When diagnostic testing reveals a bone fracture, what type of pain is the client experiencing?

acute somatic pain

A client who was a victim of domestic violence for years states to the nurse, "I know I should not feel this way, but every time I think of my former spouse, I get a horrible headache and have to go lie down." Which nursing intervention reflects practice according to the Gate-Control Theory?

administering backrub when client's head hurts

A client has a history of hearing loss and is returning for an annual hearing examination. During client education, the nurse explains that hearing involves which areas of the ear?

all sections

Which medication is used to treat glaucoma by pulling the iris away from the drainage channels so that aqueous fluid can escape?

carbachol

If untreated, squamous cell carcinoma of the external ear can spread through the temporal bone causing which of the following?

facial nerve paralysis

The nurse recognizes which statement is true of chronic pain?

It may cause depression in clients.

The student is explaining the factors affecting sensory stimulation to his professor. The professor knows that which of the student's statements is most accurate?

"Religious norms within a culture influence the amount of sensory stimulation a person seeks."

A client is diagnosed as having serous otitis media. When describing this condition to the client, which of the following would be most accurate?

"You have some fluid that has collected in your middle ear but no infection."

A client's vision is assessed at 20/200. The client asks what that means. Which is the most appropriate response by the nurse?

"You see an object from 20 feet away that a person with normal vision sees from 200 feet away."

When performing the Weber test, where would the nurse place the vibrating tuning fork? Identify the area on the accompanying figure.

(After striking the tuning fork to produce vibration, the nurse would place the tuning fork on the patient's head or forehead to assess for bone conduction using the Weber test.)

The nurse is assessing the pain of a preschooler. Which pain scales would be appropriate for the nurse to utilize? (Select all that apply.)

-FLACC Scale -Wong-Baker Faces Scale -COMFORT scale

A nurse who provides care in a long-term setting is aware of the need to promote and protect sensory stimulation for residents. What interventions should the nurse choose in order to achieve this goal? Select all that apply.

-Regularly assess residents for age-related sensory losses. -Regularly reorient residents who are disoriented to person, place, or time. -Ensure that residents who require assistive devices are regularly using them. -Assess residents for the CNS effects of drugs and the potential for polypharmacy

When evaluating the plan of care for a client receiving opioid analgesics for pain management, the nurse considers the plan successful when what occurs? (Select all that apply.)

-Therapeutic response is achieved and discomfort is reduced. -An adequate breathing pattern is maintained. -Client maintains adequate nutritional status.

A client with vertigo is scheduled to have an electronystagmography in 2 weeks. What should the nurse instruct the client to do prior to the test? Select all that apply.

-Withhold caffeine and alcohol 48 hours before the test. -Withhold antivertigo agents for 5 days before the test.

The nurse is assessing a group of assigned clients. Which client's does the nurse determine are more sensitive to sensory alterations? Select all that apply.

-a 75-year-old male admitted to the hospital for urinary tract infection -a 75-year-old client taking narcotic pain medication for a fractured hip -a 50-year-old client who works in a baseball stadium -a 65-year-old client who serve in the Vietnam War and is living alone

The client has just returned from surgery. The client asks you for an extra dose of pain medication. What would be some signs that the client is in severe pain? Select all that apply.

-elevated respiratory rate -decreased blood pressure

The health care provider has ordered 0.2 mg naloxone to be administered intramuscularly stat. The pharmacy has available naloxone 0.4 mg/mL. How much naloxone will the nurse administer to the client?

0.5

The client has been in the intensive care unit for several days. The client appears to be sleeping throughout the night. The nurse records the data listed above. The nurse evaluates that rapid eye movement (REM) sleep is occurring at:

0100.

The nurse is teaching a first-time parent about the newborn's sleep needs. The nurse would inform the parent that newborns sleep approximately how many hours per day?

14 to 18 hours

A client is receiving phenylephrine eye drops in preparation for ophthalmoscopy. The client receives the final dose of drops at 10:30 a.m. The nurse informs the client that he will begin to notice the effects of the drug beginning to wear off around what time?

1:30 p.m.

The initial target for intraocular pressure (IOP) among patient with elevated IOP and those with low-vision glaucoma with progressive visual field loss is typically set at what percentage?

30% lower than the current pressure

Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?

A chronic opioid therapy plan

A dietary modification for a patient with Ménière's disease would be:

A decrease in sodium intake to 2,000 mg daily.

A client's family asks why the nurse has placed suction equipment in the room immediately after administering a dose of naloxone. Which explanation by the nurse is correct?

Abrupt reversal of opioid-induced respiratory depression may cause vomiting.

A client has newly diagnosed cirrhosis and has pulled his nasogastric (NG) tubing for the third time. His ammonia level is above normal. Which nursing diagnosis is appropriate for this client?

Acute Confusion

The nurse admits a client to the emergency department who has been referred by the eye clinic. Which condition is an emergency where the nurse should refer the client for medical treatment immediately?

Acute angle-closure glaucoma

Which type of glaucoma presents an ocular emergency?

Acute angle-closure glaucoma (Acute angle-closure glaucoma results in rapid progressive visual impairment.)

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:

Acute angle-closure.

A nurse is preparing a plan of care for a client with otitis externa. Based on the typical assessment findings, which of the following would the nurse most likely identify as the priority nursing diagnosis?

Acute pain related to inflammation

The nurse is caring for a client with chronic back pain due to inoperable spinal stenosis. Which strategies, suggested by the nurse, may help to decrease the client's back pain?

Adding the use of hot or cold packs for pain control

Which term refers to the absence of the natural lens?

Aphakia

The nurse is demonstrating how to perform punctual occlusion. Which activities does the nurse perform?

Applies gentle pressure bilaterally on the bridge of the nose to the inner canthus of each eye

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.

High doses of which medication can produce bilateral tinnitus?

Aspirin

The nurse observes that a new client's medication regimen includes sumatriptan. What assessment should the nurse prioritize?

Assessing the client for migraine pain

Students are reviewing information about orbital and ocular tumors. They demonstrate understanding of the material when they identify which of the following as the most common malignant tumor of the eyelid?

Basal cell carcinoma

A client you are caring for has a hearing loss. The client tells you he is self-conscious about his hearing loss. What advice should the nurse give a self-conscious client with hearing loss to protect his self-esteem?

Be forthright and inform others about the hearing deficit.

Which of the following medications needs to be withheld for 5 to 7 days prior to cataract surgery?

Coumadin

The client has difficulty swallowing and requests the nurse to crush all the medications. The nurse notes a client prescribed an extended-release opioid requests that all medications be crushed to facilitate the administration. What information about this form of opioid presents a problem respecting the client's request?

Crushing the medication may precipitate an overdose.

The nurse is preparing a care plan for a client recently diagnosed with obstructive sleep apnea. The client reports daytime sleepiness, fatigue, and excessive snoring that "wakes me up." What nursing diagnosis would be appropriate for this client?

Disturbed Sleep Pattern related to periods of apnea as evidenced by excessive snoring

A client with peripheral neuropathy states, "Sometimes I get the worst pain from just a bedsheet brushing over my foot." What is the nurse's most appropriate action?

Document the client's allodynia.

Health teaching for a patient who suffers from motion sickness would include recommending the use of which one of the following over-the-counter drugs?

Dramamine

A client is to receive a narcotic that will be applied transdermally. The nurse identifies this as which agent?

Fentanyl

A nurse is assessing a client's pain level. Which would be the most appropriate method?

Have the client rate it on a scale of 1 to 10.

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?

How does the pain develop and progress?

A nurse notes that a client admitted to a long-term care facility sleeps for an abnormally long time. After researching sleep disorders, the nurse learns that which area of this client's brain may have suffered damage?

Hypothalamus

A client informs the nurse that she is not able to recall her phone number or address, and this is disconcerting. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory

A client with chronic open-angle glaucoma is now presenting with eye pain and intraocular pressure of 50 mm Hg. An immediate iridotomy is scheduled. Which of the following describes the desired effects of this procedure?

Improve outflow drainage

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear?

Inner ear

A client comes to the walk-in clinic complaining of a "bug in my ear." What action should be taken when there is an insect in the ear?

Instillation of mineral oil

The nurse assesses that the client is having pain. The nurse askes the client to rate his pain on the pain scale. The client is unable to rate the pain, stating that it just hurts so bad he can't think. What is the most appropriate response of the nurse?

Medicate the client for pain.

A nurse is caring for a client experiencing new onset confusion. What should the nurse do to avoid injuries from falls?

Monitor the client frequently.

The nurse is providing health education to a client prescribed almotriptan for the treatment of migraines. The nurse should caution the client about what potential adverse effects?

Numbness and chest tightness

The client is a 76-year-old who reports difficulty falling asleep and daytime drowsiness. Which figure best reflects REM and NREM cycles of this client?

Older adult clients tend to have greater difficulty falling asleep and more frequent awakenings which result in daytime drowsiness. This is best reflected in Answer D. (purple chart)

There are four major types of ophthalmic procedures to complete a glaucoma examination. If the health care provider wants to inspect the optic nerve, the nurse would prepare the patient for:

Ophthalmoscopy.

What condition identified in the client's history would be a contraindication for the use of estradiol?

Pulmonary emboli

The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential?

Raise your hand when you no longer hear sound.

Which statement is accurate regarding refractive surgery?

Refractive surgery is an elective, cosmetic surgery performed to reshape the cornea.

The nurse is instructing the client with dried cerumen blocking the ear canal on potential methods to reduce symptoms. Which at-home methods of cerumen removal are discouraged?

Removing the cerumen by means of a cotton tip applicator

A nurse is caring for a postsurgical client whose pain is being treated with the opioid hydromorphone. The nurse's most recent assessment reveals that the client is drowsy and drifting off during conversation with the nurse; however, the client can be aroused. What is the nurse's most appropriate action?

Report this finding to the primary care provider and seek a decrease in the client's opioid dosing.

The nurse is caring for a client ordered for multiple eye screening. Following which procedure will the nurse instruct the client on a yellow coloring to the skin and urine as being normal?

Retinal Angiography (The nurse is most correct to instruct the client that his skin and urine may turn yellow following a retinal angiography.)

Which test uses a tuning fork shifted between two positions to assess hearing?

Rinne

The nurse is examining the area behind the patient's auricle and sees a flaky scaliness. What disorder does the nurse suspect the patient has?

Seborrheic dermatitis

The nurse is assessing a client for objective symptoms of hearing difficulties. Which symptom leads the nurse to take alternate measures to ensure client understanding of teaching?

The client leans forward and turns the head.

A client is worried and states, "I just know I won't be able to sleep before my surgery." What sleeping pattern would the nurse anticipate?

The client will likely not be able to sleep.

The nurse is caring for a client with symptoms of ototoxicity from aminoglycoside administration. On which structure does the medication produce the ototoxic effect?

The eighth cranial nerve

A young client is being seen by a pediatric ophthalmologist due to a recent skateboarding accident that resulted in trauma to the right cornea, and is now at risk of developing an infection. Which nursing intervention would be contraindicated for a client at risk for infection?

To ensure correct application of antibiotic ointment, gently drag tip of tube along lower lid while squeezing ointment on to lid.

A client accidentally splashes chemicals into one eye. The nurse knows that eye irrigation with plain tap water should begin immediately and continue for 15 to 20 minutes. What is the primary purpose of this first aid treatment?

To prevent vision loss

A client diagnosed with migraines associated with the menstrual cycle has been prescribed estradiol. When providing client teaching, what preferred route of administration will the nurse describe?

Transcutaneous

A client who is a competitive swimmer is diagnosed with swimmer's ear (otitis externa). Which instruction would be least appropriate for the nurse to include when teaching the client about this condition?

Use a hair dryer set on high to dry the ear canal after swimming.

Acoustic neuromas are benign tumors of which of the following cranial nerves?

VIII

A nurse is preparing a presentation for a local community about hearing loss and prevention. Which of the following would the nurse integrate into the presentation as the most effective preventive measure?

Wearing ear protection when exposed to noise

A client tells the nurse that the client often has a difficult time falling asleep at night. What suggestion offered by the nurse may assist the client in achieving sleep?

a snack containing carbohydrates and protein

A nurse is discussing sleep with a group of orienting unlicensed personnel. The nurse explains that the older adults can have issues with physical safety in relation to the sleep patterns because:

they may be disoriented on awakening.