Sensory N102 Exam 6
A patient being sent home from a clinic after evaluation for a perforated eardrum is advised not to shower. Which statement indicates that the patient understands why showering should not be performed?
Water should not enter the ear
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:
Whites
Which nursing action is most appropriate when communicating with a client who has a hearing deficit?
Writing ideas or pantomiming as appropriate in order for the client to understand
A nurse is caring for a client with a genetic nerve disorder who has difficulty when attempting to move her tongue. The nurse recognizes that this may indicate a deficit in the functioning of which cranial nerve?
XII
The nurse would be most concerned about the risk of malnutrition for a patient with which sensory deficit?
Xerostomia
A patient with diabetic retinopathy is being discharged home. Which patient statement indicated understanding of the discharge plan to maintain vision?
"I should keep my diabetes under control"
The nurse is reinforcing teaching provided to a patient recovering from a stapedectomy. Which patient statement indicates teaching has been effective?
"I will cough or sneeze with my mouth open"
Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability?
"Are you able to prepare a meal or write a check?"
A 54-year-old client expresses concern about her weakening sense of smell to the nurse during an admission interview. The nurse's most therapeutic response is:
"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"
The nurse is reinforcing teaching provided to a patient with Menieres disease. Which patient statement indicates understanding of how to manage the vertigo?
"Avoid sudden movement"
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:
"Bring something from home for her to display in her room"
1) After being diagnosed with cataracts, a client believes the right eye has a cataract but not the left eye, as there are no vision changes with the left eye. Which response by the nurse is accurate?
"Cataracts develop at different rates, so one eye may be more affected than the other."
A patient diagnosed with cataracts asks how they develop. What should the nurse respond to this patient?
"Cataracts may form as a result of exposure to ultraviolet light over time"
A nurse is providing teaching to a young adult client who is occasionally exposed to loud explosions on the job site. Which statement on the part of the client indicates that he accurately understands the potential risk to his hearing?
"Damage to the ear from loud noises can cause permanent hearing loss."
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 doesn't interact with people like he used to." Which of the following is the nurse's most therapeutic response?
"Do you think he may be having difficulty hearing what people are saying to him?"
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 nurse's inquiry, "Do you own safety glasses?"
"Do you wear them each time you use your tools?"
A 47-year-old male client has come in to his primary health care provider's 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?
"Do you work in a noisy environment?"
The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement indicates a correct understanding of the teaching?
"Headache and seeing halos around lights"
6) A nurse is evaluating the care received by a client who has a hearing deficit. Which statement indicates that the client is effectively addressing variables that may lead to social isolation?
"I ask others to face me when they talk because I can hear them better."
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?
"I have my eyes checked yearly to be aware of any retinopathy that may be developing."
Which of the following statements made by the nurse shows the greatest insight into the possible causes of a hearing-impaired client's irritability?
"I know he doesn't hear well, but I wonder if his increased lack of patience today has to do with being in pain."
A patient diagnosed with myopia asks the nurse to explain the condition. How should the nurse respond?
"It is nearsightedness"
Which of the following occupations poses the least risk for sensory alterations?
Waiter
27) Laser surgery and photodynamic therapy are both treatments for what disease of the eye?
Exudative macular degeneration
14) The nurse is evaluating instructions provided to a client with glaucoma. Which client statement indicates that teaching has been effective?
"I must use my eyedrops as prescribed for the rest of my life."
The nurse is having difficulty communicating with a hearing-impaired patient. Which action should the nurse take to improve communication?
Face the patient when speaking
A nurse is caring for an elderly patient who was in a motor vehicle accident because he thought the stop light was green. The patient asks the nurse if he should no longer drive. Which response by the nurse is most therapeutic?
"No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is illuminated, it means stop, and if the bottom is illuminated, it means go."
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:
"Remember to keep your car maintained with regular checkups"
A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse would be most appropriate for this patient?
"Rinse your mouth several times a day to hydrate your taste buds."
The caregiver of a patient with macular degeneration. The patient's caregiver becomes increasingly frustrated because of food spills on the patients clothing. Which explanation should help the caregiver understand what the patient is experiencing?
"The central vision is gone and only peripheral vision remains"
6) The nurse is caring for a client who receives vitamin B12 injections to control her peripheral neuropathy. The client tells the nurse that she recently started experiencing increased tingling in her fingers and toes, and she asks the nurse what this means. How should the nurse reply?
"The tingling suggests that you are due for another injection."
18) A nurse is caring for a client with glaucoma who is prescribed an ophthalmic beta-adrenergic blocking agent. When teaching the client about the therapeutic action of this medication, which of the following statements should the nurse include?
"This drug reduces intraocular pressure by decreasing the production of fluid in the eye."
The nurse is teaching a patient about conjunctivitis. Which statement indicates that the patient understands the most important means to prevent the spread of this infection?
"Wash hands"
The nurse and a 62-year-old client are discussing the client's sense of hearing. Which of the following assessment questions is most likely to launch a conversation concerning the client's ability to hear effectively?
"Would you rate your hearing as excellent, good, fair, poor, or bad?"
The nurse and a 69-year-old client are discussing the client's 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 client's assumption of the cause of the diminished hearing?
"You may be right, but I suggest you see an otolaryngologist just to be sure."
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 client's 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 client's daughter is:
"Your mother appears to have aphasia as a result of her stroke."
13) The nurse is providing teaching to a client who was prescribed an ophthalmic beta blocker for glaucoma. The client is having difficulty understanding how to self-administer the medication. Which instruction by the nurse is best?
"close your eyes"
3) Which is the decibel level for mild hearing loss?
16-40 dB
After surgery for a detached retina, a patient is experiencing nausea and is prescribed phochloroperazine (compazine) 10 mg IM prn every 6 hours. Compazine is available as 5 mg/ml. The nurse should administer _________ mL in each dose
2 mL
22) Which of the following clients most likely will require assistance with properly taking medications for macular degeneration?
67-year-old client, dementia, arthritis, no hypertension
17) Which of the following scenarios is consistent with secondary congenital glaucoma?
A 1-year-old infant develops glaucoma following neurofibromatosis.
7) Which client's clinical manifestations are most consistent with Guillain-Barré syndrome?
A 5-year-old client feels leg pain and wants to be carried.
8) A school nurse is identifying students who may have hearing loss. Which student would the nurse be most concerned about?
A child who cannot follow conversations in the hallways between classes or in the cafeteria
10) Which assessment finding is consistent with a diagnosis of open-angle glaucoma?
A client experiences gradually diminishing vision in both eyes over an extended period.
10) A nurse is working with several clients who are experiencing hearing loss. Of these clients, which is the best candidate for a cochlear implant?
A client with sensorineural hearing loss from long-term exposure to loud noise
9) Which of the following diagrams would the nurse use when describing open-angle glaucoma to a client?
A diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm
What is vertigo?
A feeling of rotation or imbalance
The nurse is aware that which patient is most at risk for sensory deprivation?
A patient on the unit with tuberculosis on airborne precautions
The nurse would utilize the Snellen chart for assessment of which patient?
A patient who frequently reports the incorrect time from the clock across the room
Which nursing assessment best measures cognitive functioning?
Administer a Mini-Mental Status Exam (MMSE).
2) Which assessment finding supports the nurse's conclusion that a client is at risk for cataracts?
Age 75 years
28) What class of drugs both decreases production of aqueous humor in the eye and increases drainage of aqueous humor from the uveoscleral pathway?
Alpha2-adrenergic agonists
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?
Altered spatial perception
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?
An African American with hypertension
The nurse is planning care for an older adult client diagnosed with age-related macular degeneration (AMD) that is nonexudative. Which therapies should the nurse anticipate for this client?
Antioxidants Zinc
It has been determined that a vision problem has contributed to a client's ability to provide self-care regarding bathing, dressing, and toileting. The initial nursing responsibility regarding these deficits is to:
Arrange for in-home services to facilitate the client's ability to remain as independent as possible regarding ADLs
A patient scheduled for cataract surgery asks if the surgery is safe. What should the nurse do?
Ask the surgeon to talk to the patient
The nurse is caring for a newly admitted client who is aphasic. The nurse most therapeutically addresses the communication issue by:
Asking the client how he or she wants to communicate with the staff
The nurse is working with older adult clients in an extended care facility. To enhance the clients' gustatory sense, the nurse should:
Assist with oral hygiene
13) Which of the following best describes tinnitus?
Auditory perception without external auditory stimuli
29) Which best describes photophobia?
Aversion to light
The nurse is contributing to the plan of care for a patient recovering from a myringoplasty. Which intervention should be included in this patient's plan of care?
Avoiding excessive movement
A nurse is caring for a patient who is experiencing vertigo. Which nursing intervention would assist the patient in controlling the vertigo?
Avoiding riding in vehicles and making sudden motions
A patient informs the nurse that she often becomes nauseated when riding in motor vehicles. The nurse knows that this is related to which sensory deficit?
Balance deficit
The nurse notes that a patient has astigmatism. What should the nurse expect when collecting data from this patient?
Blurred vision
11) An older adult client is using prescription eyedrops to treat her glaucoma. When providing client teaching about this medication, which of the following should the nurse mention as potential side effects? Select all that apply.
Blurred vision Change in eye color
30) Which statement about cataract surgery is correct?
Cataract surgery should be quick but may have to take place in stages.
10) Which degree of alcohol use has been implicated in the development of alcohol-related neuropathy?
Chronic and heavy
4) A client with peripheral neuropathy complains of leg aches and the inability to be comfortable. Which nursing diagnosis would be a priority for the client at this time?
Chronic pain
A patient with acute ear pain and drainage comes into the community clinic. Which diagnostic tests should the nurse prepare to collect prior to beginning treatment for this patient?
Complete blood count Rinne and Weber tests Culture of ear discharge
A nurse is caring for a patient with right-sided weakness following a stroke. Which nursing action would be least effective in promoting positive adaptation of the patient's sensory deficit?
Completing sentences that the patient cannot finish
The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is more important for the nurse to include in the patient teaching?
Compliance with drug therapy is essential to prevent loss of vision
5) Which client should the nurse identify as having the greatest risk for hearing loss?
Construction worker who typically works in urban centers
21) An older adult client with intermediate dry macular degeneration calls the nurse complaining that his vision is suddenly much more distorted and colors do not seem right. Which action by the nurse is priority?
Contact the healthcare provider for an immediate ophthalmologic evaluation.
A patient with acute angle glaucoma and a fractured femur that is scheduled for surgery is prescribed the preoperative medications morphine 10 mg intramuscularly (IM), and atropine 0.4 mg IM. Which action should the nurse take?
Contact the physician
The nurse is reinforcing teaching provided to a patient being treated for myopia. Which patient statement indicates a correct understanding of the teaching?
Corrective concave lenses are needed
The nurse is identifying nursing diagnoses appropriate for a client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. Which diagnosis would be the lowest priority for this client?
Nausea
A patient with glaucoma is prescribed pilocarpine 1% eye drops every 6 hours. What outcome should the nurse expect from this medication?
Promotion of drainage of aqueous humor from the anterior chamber of the eye
The nurse teaches a client that prolonged use of the antibiotic streptomycin may result in:
Damage to the auditory nerve
A patient with Menieres disease is crying and wants to know why this disease is occurring. Which outcome should the nurse recommend for this patient's care?
Decrease anxiety
With advancing age, which of the following normal physiological changes in sensory function occurs?
Decreased sensitivity to pain
12) What is conductive hearing loss?
Disruption of the transmission of sound from the external auditory meatus to the inner ear
2) The nurse is providing teaching to a client at risk for acquired peripheral neuropathy. Which of the following activities should the nurse suggest the client modify or avoid to reduce the risk of this condition?
Drinking one six-pack of beer per day
5) The nurse is planning care for a client scheduled for cataract surgery. Which intervention should the nurse include in the plan of care to help provide a safe environment for the client following surgery?
Ensuring fall hazards are removed from the client's home and additional lighting is provided
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 client's safety related to medication administration?
Evaluate the client's ability to read the frequency and dosage information on his medication bottles.
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:
Every 1-2 years
The nurse is assisting with the auditory assessment phase of the physical examination for a high school swimming team. The nurse identifies a student who has pain and itching of the ear. For which disorder should the nurse anticipate treatment is needed?
External otitis
The nurse is caring for a patient who is a well-known surgeon at the hospital. Because of his status, all the hospital's physicians want to be sure to pay him a visit. The nurse notices the patient becoming more agitated and withdrawn with each group of visitors. The nurse asks the patient if he would like a "Do not disturb" sign placed on the door. A few hours later, the nurse notices a physician who is not involved in the patient's care attempting to enter the room. Which response by the nurse is most appropriate?
Firmly explaining that the patient does not wish to have visitors at this time, so do not enter the room
The nurse is selecting sensory aids for a client with deficits in hearing and sight. Which aid would address both sensory deficits?
Flashing alarm clock with large numbers
11) What is characteristic of conductive hearing loss?
For loss of hearing to be the same at all frequencies
The nurse is caring for a patient with a sensorineural hearing loss. Which prescribed medications should the nurse question before providing to this patient?
Gentamicin Furosemide Indomethacin
The nurse is providing teaching on the recommended hearing tests for older adults. Which information should be included in this teaching?
Have a hearing test every 10 years until age 50 and then every 3 years.
The nurse is caring for a patient with chronic otitis media. For which complication should the nurse observe in the patient?
Hearing loss
The nurse is collecting data from an AA patient who has Meniere's disease. Which finding should the nurse expect?
Hearing loss, vertigo, and tinnitus
15) The nurse is caring for a client who has been using timolol (Timoptic) to manage glaucoma. Which assessment finding supports an adverse effect associated with systemic absorption of the drug?
Heart rate of 57
The nurse is caring for a patient who has an acute attack of Menieres disease. What action should the nurse take first?
Help the patient into bed with side rails up
24) The nurse is caring for a client in the early stage of macular degeneration. What dietary changes should the nurse recommend to slow the progression of the disease?
High-antioxidant diet
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?
I will warn you of upcoming curbs or stairs
The nurse in the pediatric clinic is checking the basic visual acuity of a 4-year-old child. The nurse should have the child:
Identify crayon colors
6) Which diagnostic technique is used to confirm the location and extent of cataracts?
Identifying patient history consistent with risk of cataracts and examining the eye to diagnose the cataract
9) Which of the following statements regarding idiopathic neuropathy is true?
Idiopathic neuropathy has no known cause
Which of the following sensory changes are normal with aging?
Impaired night vision
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?
Improper water heater settings
Often blindness occurs during childhood. Which health preventative measure is most appropriate to prevent vision impairment?
Include rubella and syphilis screening in the preconception care plan.
The nurse is reinforcing teaching provided to a patient with Menieres disease. Which discharge order should the nurse question?
Increase daily sodium intake to 4 g
26) The home care nurse is assessing a client with macular degeneration. What interventions would be appropriate to ensure home safety for this client?
Keep the stairs free of clutter. Have grab bars installed in the bathroom. Remove scatter rugs from the floors in the home.
The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except her location. Which nursing intervention would be effective in orienting a patient with neurological deficit?
Keeping a day-by-day calendar at the patient's bedside and having the patient manage it
The client has hyperesthesia apparently associated with a neurological trauma. Which of the following is an appropriate nursing intervention in regard to the client's sense of touch?
Keeping the client loosely covered with sheets and blankets
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?
Keeping the client's lights dimmed and curtains partially drawn
The nurse is conducting a prenatal assessment on a client. Which finding indicates a risk of sensory impairment in the unborn child?
Lack of immunity to rubella
The nurse is caring for a patient after a left stapedectomy. In which which position should the nurse place the patient?
Left ear upward
The primary safety issue related to the presence of a taste deficit in a young child is there will most likely be:
Little discretion for ill-tasting substances
The nurse is teaching a patient with glaucoma how to instill eyedrops. Which action should the nurse instruct the patient to take?
Look up while pulling lower lid outward
The nurse is collecting data from a patient with a detached retina. Which findings should the nurse expect in this patient?
Loss of acuity in the affected eye
The nurse is collecting data from a patient with cataracts. Which symptom should the nurse expect because of this health problem?
Loss of visual acuity
19) An older adult client tells the nurse that reading is easier when the material is held to the left or right. What should the nurse suspect this client is experiencing?
Nonexudative macular degeneration
The nurse suspects that an older adult client has a hearing disorder; however, the client denies not being able to hear, and the family thinks the client is just becoming more absent minded with age. Which initial action by the nurse to assess the client's hearing is appropriate?
Observe the client's interaction with family.
A patient with otitis media is experiencing severe ear pain. Which nonpharmacologic measures should the nurse use to help this patient?
Offer a massage Apply heat to the area Offer liquid or soft diet
What nursing action can the nurse implement to comfort an elderly patient with sensory deprivation to improve meaningful stimuli?
Offering the patient a back rub
3) A nurse is caring for several pediatric clients who are affected by cataracts. Of these clients, which is the most obvious candidate for surgical removal of the cataract?
One-month-old infant with no reaction to bright light and failure to notice toys or faces
7) Which strategy for communication enhancement incorporates the use of shapes?
Oral approach
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:
Orient the client to the location of the foods on the plate (clock method)
Which of the following safety measures is most important for the nurse to implement for a hospitalized client with a visual impairment?
Orient the client to the room.
The nurse is collecting data from a patient who has a bulging eardrum. For which health problem should the nurse anticipate providing care to this patient?
Otitis media
Which diagnostic test should the nurse use to assess hearing in an infant?
Otoacoustic emissions test
The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which desired outcome should be included in the plan of care?
Patient will communicate nonverbally
A nurse is administering a vaccine to a 4-year-old child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" The nurse knows that the ability to recognize and interpret stimuli is known as
Perception
A home health nurse is assembling a puzzle with an elderly patient and notices that the patient is having difficulty connecting two puzzle pieces. The nurse knows that this is most likely related to which aspect of sensory deprivation?
Perceptual
A nurse is establishing a relationship with the patient who is visually impaired. Which is the most appropriate method to teach the patient how to contact the nurse for assistance?
Place a raised Braille sticker on the call button, and instruct the patient to press for assistance.
The home health nurse is caring for a patient with a tactile deficit; the nurse is concerned about injury related to inability to feel harmful stimuli. The nurse evaluates that the patient is able to safely care for himself when the patient demonstrates which action?
Places colored stickers on faucet handles to indicate temperature and keeps a thermometer near the tub
1) A client with a long history of type 2 diabetes mellitus complains of occasional coldness and numbness in both hands and both feet. These complaints are suggestive of which condition?
Polyneuropathy
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.)
Poor night vision Reduced peripheral vision Reduced depth perception Increased sensitivity to glare Diminished color perception
The nurse is planning to perform an ear irrigation to remove a patients cerumen. Which patient condition would contraindicate this procedure?
Previous perforated eardrum
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?
Provide pictures of the client's family.
The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over inability to sleep. Which action by the nurse is most appropriate for this patient?
Provide the patient with earplugs
The nurse is caring for a patient recovering from a stapedectomy. What is the priority nursing action to maintain safety?
Put the side rails up
What is the involuntary motion of retracting the body from painful stimuli?
Reaction
What are the two components of the sensory process?
Reception and perception
The nurse is caring for a patient who is having difficulty understanding written and spoken word? The nurse suspects the patient has _____ aphasia.
Receptive
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:
Red and yellow
A client is experiencing visual overstimulation. What can the nurse do immediately to reduce this client's visual sensory overload?
Reduce the amount of light in the room by lowering shades and turning off overhead lights.
5) The nurse is planning care for an adolescent client recently diagnosed with Charcot-Marie-Tooth syndrome. Which intervention is the highest priority?
Reducing the client's risk for injury
23) The nurse is preparing discharge instructions for a client with age-related macular degeneration (AMD) and type 1 diabetes mellitus. What should the nurse include in this client's teaching plan?
Referral to home care to ensure safety with administering insulin and AMD medications at home
4) An older adult client with bilateral cataracts, arthritis, and a hearing deficit is scheduled for cataract surgery. Which is the priority nursing diagnosis for this client?
Risk for Ineffective Health Maintenance
The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis addresses the complication of the sensory deficit that places the patient at greatest risk for injury?
Risk for falls
The nurse is developing a plan of care for a patient who is having a prosthetic eye placed. Which nursing diagnosis related to patient safety is the priority for the nurse to include in the plan of care?
Risk for injury
The nurse has completed the admission assessment for a client admitted to the hospital's subacute care unit. Of the following nursing diagnoses identified by the nurse, the one that takes the highest priority is:
Risk for injury **safety always top priority
A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. Which tool should the nurse select to assess this client?
Rosenbaum eye chart
The nurse recommends follow-up auditory testing for a child who was exposed in utero to:
Rubella
During a home visit, the nurse identifies signs of visual impairment in a 74-year-old patient. Which action should the nurse recommend?
Schedule an eye examination
8) A client is undergoing surgery to manage glaucoma. When providing postoperative teaching to this client, the nurse should emphasize that the client is now at increased risk for which form of cataracts?
Secondary
16) The nurse is planning instruction for a client who is newly diagnosed with glaucoma. What should be included in this teaching?
Self-administer prescribed eye medication properly. Attend follow-up appointments with the physician. Avoid over-the-counter medication unless discussed with the physician.
9) A nurse is caring for a client who is receiving IV tobramycin for the treatment of a respiratory infection. Which of the following should the nurse plan on teaching the client how to do?
Self-monitor for hearing loss
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 client's emotional state is a result of:
Sensory overload
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:
Sensory overload
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:
Sitting and rocking back and forth
A home safety measure specific for a client with diminished olfaction is the use of:
Smoke detectors on all levels
20) The nurse is providing teaching to a client related to maintaining healthy vision. Which of the following should the nurse identify as a modifiable risk factor for macular degeneration?
Smoking 1 pack of cigarettes per day
Which nursing diagnosis addresses psychological concerns for a patient with both hearing and visual sensory impairment?
Social isolation
The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?
Speaking with hands, face, and expressions
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:
Stereognosis
12) The nurse is planning care for a client with glaucoma who is experiencing anxiety as a result of the diagnosis. Which intervention should the nurse select to address this need?
Support the client's use of coping mechanisms.
A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with attempting to eat his meal and is becoming tearful. The nurse includes which intervention in the patient's plan of care?
Teach the patient about special devices used to assist patients with eating meals.
Where does perception, or the awareness and interpretation of stimuli, take place?
The brain
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:
The gray/black settings on the stove handles
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.)
Vision Hearing Smell Taste Touch
A family member of an 86-year-old patient explains that the patinet sits about 2 feet away from the television and is not interested in going out anymore. Which additional information should the nurse use to support visual impairment?
The patient does not go out anymore
A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit?
The patient turns one ear toward the nurse during conversation
25) A client is receiving verteporfin treatment for macular degeneration. The client asks the nurse what the expected outcome of treatment is. Which response by the nurse is most appropriate?
The progression of the disease will be slowed.
What characterizes individuals with achromatopsia?
They perceive only shades of gray and no colors.
3) The nurse is providing client teaching on Guillain-Barré syndrome. Which explanation for a client's false perception that socks are being worn is accurate?
This disorder causes a change in sensation that makes the client feel as if socks are being worn.
7) A client has been diagnosed with cataracts of both eyes. The client's vision and activities of daily living have become severely impaired. What collaborative intervention does the nurse anticipate for this client?
Two surgical procedures, separated by a few weeks, to remove the cataracts
8) The nurse is planning teaching for a client diagnosed with diabetic neuropathy. What should the nurse include in this teaching?
Use a mirror to inspect feet daily
The nurse is working with a client with a moderate hearing impairment. To promote communication with this client, the nurse should:
Use the visual aids such as the hands and eyes when speaking
The client has experienced a cerebral vascular accident (stroke) with resultant expressive aphasia. The nurse promotes communication with this client by:
Using a picture chart for the client's respose
For a client with receptive aphasia, which one of the following nursing interventions is the most effective?
Using a system of simple gestures and repeated behaviors to communicate
The nurse is collecting data from a patient with an inner ear disorder. Which findings should be the most concerning to the nurse?
Vertigo
