Sensory

A nurse is administering brimonidine eye drops to a client who has glaucoma. Which fo the following ocular effects should the nurse expect? A. Decreased intraolcular pressure B. Blocked growth of new blood vessels C. Paralysis of accommodation D. Mydriasis

A. Decreased intraocular pressure Rationale: Brimonidine is an alpha-2 adrenergic agonist used for the long-term tx of open-angle glaucoma. It decreases intraocular pressure by reducing aqueous humor production

A nurse is assessing a client who has a head injury with a possible skull fracture. Which of the following findings should the nurse identify as an indication that the client might have a complication involving the eighth cranial nerve (CN VIII)? A. Dizziness and hearing loss B. Weakness of a side of the tongue C. Facial droop and asymmetrical smile D. Loss of the same visual field in both eyes

A. Dizziness and hearing loss Rationale: Dizziness and hearing loss reflect alterations in the vestibulocochlear area

A nurse is caring for a client who has hearing loss. The nurse should plan which of the following interventions when communicating with the client? A. attract the client's attention before speaking B. accentuate vowels of words while speaking C. touch the client at intervals when communicating D. sit at a 90-degree angle to the client when speaking

A. attract the client's attention before speaking

A nurse is providing discharge teaching to a client who is post-op following scleral buckling to repair a detached retina. Which of the following instructions should the nurse include in the teaching? A. "You can expect your vision to return immediately after the procedure" B. "You should avoid reading for 1 week" C. "You can remove eye shields when you're sleeping" D. "You should not light objects that weigh > 25 lb"

B. "You should avoid reading for 1 week" Rationale: Client should AVOID any activity that can cause rapid movement of the eye due to the risk of detachment of retina

A nurse is caring for a client who has Ménière's disease. The nurse should identify that Ménière's disease affects which structure of the ear? A. Eustachian tube B. Cochlea C. Perichondrium D. Eardrum

B. Cochlea Rationale: excess fluid distorts the inner ear canal system. distortion decreases hearing via dilation of the cochlear duct, leading to vertigo from damage to the vestibular system

A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an AP to feed the child B. Explain the sounds the child is hearing C. Have the child use a cane when ambulating D. Rotate nurses caring for the child

B. Explain the sounds the child is hearing Rationale: noises in a hospital can be frightening to a child who is experiencing a sensory loss. Explaining these noises can allay the child's fears

A nurse is assessing a client who has cataracts. Which of the following findings should the nurse expect? A. Pupils nonreactive to light B. Opacity visible behind the pupil C. White circle around the outside border of the iris D. Increased intraocular pressure

B. Opacity visible behind the pupil Rationale: with a cataract, the lens of the eye becomes thick and opaque w/ age and appears as opacity behind the pupil when the nurse shines a light on the area

A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following eye disorders? A. Glaucoma B. Retinal detachment C. Macular degeneration D. Cataracts

B. Retinal detachment Rationale: a flash of light and a sudden loss of vision are manifestations of retinal detachment. Client report the event of vision loss as sudden and painless

A nurse is caring for an older adult client who has moderate hearing loss. Which of the following actions should the nurse take to enhance communication? A. Speak with exaggerated lip movements B. Speak at a moderate rate C. Speak in a louder voice D. Speak using a higher pitch

B. Speak at a moderate rate Rationale: the nurse should slow the rate of speech for an older adult client who has hearing loss. However, the nurse should not speak with exaggerated slowness because this can distort words and make understanding more difficult for the client

A nurse is reviewing the medical record of a patient who might have hearing loss. Which of the following data from the client's medical record should the nurse identify as a risk factor for hearing loss? A. Frequent use of steroids B. Chronic use of salicylates C. Intermittent use of antacids D. Habitual use of laxatives

B. chronic use of salicylates Rationale: chronic use of salicylates such aspirin can lead to ototoxicity, which can manifest as tinnitus or hearing loss

A nurse is providing teaching to the partner of a client who has conversion disorder. Which of the following statements by the partner SHOWS an UNDERSTANDING of the TEACHING? A. "My partner is pretending to be ill to get attention" B. "My partner is purposefully making our child sick" C. "the stress of losing our child caused my partner to go blind" D. "My partner is worried that he has cancer, even though his tests are normal"

C. "the stress of losing our child caused my partner to go blind" Rationale: Nurse should explain to the partner that conversion disorder manifests as deficits in motor or sensory functions. Emotional conflict or stress is reflected in physical manifestations such as: paralysis, blindness, movement disorder, numbness, paresthesia, loss of hearing, or episodes resembling epilepsy

A nurse is caring for a client who is experiencing cycloplegia following the administration of atropine eye drops during an eye examination. Which of the following findings should the nurse expect as a result of cycloplegia? A. Inability to tolerate bright lights B. Pinpoint pupils C. Blurred vision D. Inability to perform an upward gaze

C. Blurred vision Rationale: Assessment findings of cycloplegia include blurred vision b/c focusing for near vision is impaired. This action occurs following the administration of atropine b/c the paralysis of the ciliary muscle prevents near-vision focus. Accommodation, or looking from far to near and vice-versa, is also temporarily impaired

A nurse is assessing a client who reports an acute visual disturbance that he describes as a "curtain" pulled over his visual field with occasional flashes of light. The nurse should notify the provider that this client might have which of the following disorders? A. Cataracts B. Angle-closure glaucoma C. Retinal detachment D. Macular degeneration

C. Retinal detachment Rationale: 911!!! w/o immediate medical attention, the entire retina can detach leading to permanent vision loss; manifestations include sudden onset of decreased peripheral or central vision, dark floaters, flashes of light, and a shadow or curtain over a part of the visual field

A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A. Multiple floaters B. Flashes of light in front of the eye C. Severe eye pain D. Double vision

C. Severe eye pain Rationale: severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations: report of halos around lights, blurred vision, headaches, brow pain, N/V

A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following? A. Olfaction B. Visual acuity C. Speech patterns D. Hand-eye coordination

C. Speech patterns Rationale: chronic otitis media can result in hearing loss, which can affect speech development

A nurse is providing teaching to a client who has a new diagnosis of Meniere's disease. Which of the following instructions should the nurse include in the teaching? A. Avoid bearing down B. Increase caffeine intake C. Avoid sudden movements D. Increase sodium intake

C. avoid sudden movements Rationale: Ménière's disease is a disorder of the inner ear affecting balance and hearing. Characterized by vertigo, hearing loss, and tinnitus. The nurse should instruct the client to avoid sudden movements that can increase manifestations

A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? SATA A. Lost vision can improve with eye drops B. Administer eye drops as needed for vision loss C. Glasses will be necessary to correct the accompanying presbyopia D. Driving can be dangerous due to the loss of peripheral vision E. Laser surgery can help reestablish the flow of aqueous humor

D. Driving = dangerous E. Laser surgery = reestablish flow of aqueous humor Rationale: Damage to the optic nerve that occurs secondary to increased intraocular pressure cause a decrease in peripheral vision and can lead to complete vision loss if not tx. Laser surgery can reopen the trabecular meshwork and widen the canal of Schlemm

A nurse is teaching a client who has myopia about laser-assisted in situ keratomileusis (LASIK) surgery. Which of the following is an adverse effect of LASIK surgery? A. Eyelid twitching B. Photosensitivity C. Intraocular hemorrhage D. Dry eyes

D. Dry eyes Rationale: LASIK is used to correct nearsightedness, farsightedness, and astigmatism by changing the shape of the cornea. ADVERSE EFFECTS: dry eyes and blurred vision

A nurse is reviewing the records of a group of older adult clients. Which of the following findings should the nurse identify as an unexpected manifestation of the aging process? A. Decreased absorption of nutrients B. Impaired excretion of medications C. High-pitched frequency hearing loss D. Obesity

D. Obesity Rationale: unexpected finding that can lead to cardiovascular disease, diabetes and stroke