Sensory Perception

A patient says, "What is that awful smell?" What sense is being used? A. Olfactory B. Gustatory C. Tactile D. Auditory

A

A nurse is caring for a patient who is post-operative. The IV pump and telemetry monitor are alarming and the roommate is watching TV at a loud volume. The patient is experiencing incisional pain and discomfort from the urinary catheter. Identify the sensory alteration the patient is at risk of experiencing. A. Sensory deprivation B. Sensory overload C. Sensory deficit D. Sensory processing disorder

B

The nurse is developing a plan of care for the client scheduled for cataract surgery. The nurse documents which more appropriate nursing diagnosis in the plan of care? A. Self-care deficit B. Imbalanced nutrition C. Disturbed sensory perception D. Anxiety

Correct Answer: C The most appropriate nursing diagnosis for the client scheduled for cataract surgery is Disturbed sensory perception (visual) related to lens extraction and replacement. Although the other options identify nursing diagnoses that may be appropriate, they are not related specifically to cataract surgery.

When assessing a 45-year-old patient's sensory status, which assessment finding does the nurse consider a normal part of aging? A. Presbyopia and the need for glasses for reading. B. Reduced sensitivity to odors. C. Impaired balance and coordination. D. Reduced taste discrimination.

A

Your patient has several risk factors that increase his risk for developing cataracts. What preventive measures can you educate the patient about? Select All That Apply A. Wearing large brim hats while in the sun B. Eating a diet rich in vegetables and fruits C. Quit smoking D. Reducing alcohol consumption E. Managing blood glucose levels F. Scheduling regular eye exams

A,B,C,D,E,F

A 74-year-old patient has returned to the nursing home, following surgical removal of bilateral cataracts, reports feeling a little uncertain about walking by herself. Which approach will the nurse use to assist her with ambulation? A. Walk one-half step behind and slightly to her side, utilizing a gait belt. B. Have her grasp your arm just above the elbow and walk at a comfortable pace, warning her when you approach obstacles. C. Provide her with a wheelchair to use for the next week. D. If she requires assistance, place your hand around her waist

B

A nurse is providing discharge instructions for a client following cataract surgery with insertion of an intraocular lens. Which of the following instructions should the nurse include? A. "Take aspirin for discomfort." B. "Restrict lifting objects greater than 10 pounds." C. "Expect reduced vision for 48 hours after the procedure." D. "Apply warm compresses for discomfort."

B

A patient with glaucoma is ordered eye medication for the right eye in the form of an ointment and eye drop. The nurse will administer which type of medication first? A. Ointment and then the eye drops B. Eye drops and then the ointment

B

The nurse is caring for a client who has visual impairment. Which intervention is the nurse's priority? A. Provide education to the patient B. Ensure the patient's safety C. Offer to assist the patient at mealtime. D. Schedule an eye exam for the patient

B

The patient is ordered to take Timolol for the treatment of glaucoma. Before administration the nurse will educate the patient about this new medication. Which of the following information is the MOST pertinent the nurse to include? A. Measuring the heart rate because this medication can cause tachycardia. B. Performing punctal occlusion after instilling the eye drops. C. Avoid taking this medication with any other glaucoma medications. D. Always administer this medication 1 minute before another type of glaucoma medication.

B

Which nonpharmacologic nursing intervention may be used to promote relaxation without also causing sensory overload? A. Taking a long walk around the hospital. B. Using headphones to listen to music of the patient's choice C. Talking with other patients in the patient lounge. D. Watching a reality television show that their visitor has selected.

B

You're providing care to a patient who just had glaucoma surgery. The patient is alert and oriented. Vital signs are: heart rate 82 bpm, blood pressure 110/80, oxygen saturation 97% on room air, respiratory rate 18, and pain rating of 2 on 1-10 scale. Which patient finding below requires you to notify the physician? A. The patient reports blurred vision. B. The patient is having difficulty passing stool and reports constipation. C. The patient reports that the eyes feel itchy. D. The patient's eyes are frequently tearing up.

B

A nurse is teaching a lawn-care worker about the risk of hearing loss. What might be recommended? A. "Listen to music with earphones while mowing." B. "Just ignore the noise, you are too young for damage." C. "Wear earplugs while using lawn equipment." D. "Be sure to wear protective glasses when mowing."

C

During a hearing assessment, the nurse notes that the sound lateralizes to the clients left ear when performing the Weber test. How does the nurse interpret these findings? A. A normal finding. B. A conductive hearing loss in the right ear. C. A sensorineural or conductive loss. D. The presence of nystagmus.

C

The nurse completes an assessment of a 69-year-old female patient who is being seen for the first time in the clinic. During the examination, the patient's temperature is 37.6°C, heart rate 86 beats/min, respiratory rate 18 breaths/min, and blood pressure 142/84 mmHg. She appears inattentive as the nurse asks questions. The patient consistently smiles and nods in agreement as the nurse speaks. When answering questions, she speaks loudly. What does the nurse's assessment indicate? A. Visual deficit. B. Patient is normal. C. Hearing deficit. D. Sensory overload.

C

What term is used to refer to the awareness of the position of body parts and movement? A. Stereognosis B. Visceral C. Kinesthesia D. Reception

C

A nurse is performing an assessment on a patient admitted to the emergency department with eye trauma. Identify the nurse's priority interventions. (Select All That Apply) A. Conducting a home safety assessment and identifying hazards in the patient's living environment. B. Reinforcing eye safety at work and in activities that place the patient at risk for eye injury. C. Placing necessary objects such as the call light and water in front of the patient to prevent falls due to reaching. D. Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye.

C,D

What signs and symptoms are present with angle-closure glaucoma? Select All That Apply A. Patients are mainly asymptomatic B. Gradual loss of peripheral vision C. Sudden vision changes (halos around lights or blurred vision) D. Severe eye pain E. Corneal edema F. Nausea and vomiting G. Red eyes H. No pain

C,D,E,F,G

During the early postoperative period, the client who had a cataract extraction complains of nausea and severe eye pain over the operative site. The initial nursing action is to: A. Call the physician B. Administer the ordered main medication and antiemetic C. Reassure the client that this is normal. D. Turn the client on his or her operative side

Correct Answer: A Severe pain or pain accompanied by nausea is an indicator of increased intraocular pressure and should be reported to the physician immediately. The other options are inappropriate.

Which of the following symptoms would occur in a client with a detached retina? A. Flashing lights and floaters B. Homonymous hemianopia C. Loss of central vision D. Ptosis

Correct Answer: A Signs and symptoms of retinal detachment include abrupt flashing lights, floaters, loss of peripheral vision, or a sudden shadow or curtain in the vision. Occasionally visual loss is gradual.

The client with glaucoma asks the nurse is complete vision will return. The most appropriate response is: A. "Although some vision as been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan." B. "Your vision will return as soon as the medications begin to work. C. "Your vision will never return to normal." D. "Your vision loss is temporary and will return in about 3-4 weeks."

Correct Answer: A Vision loss to glaucoma is irreparable. The client should be reassured that although some vision has been lost and cannot be restored, further loss may be prevented by adhering to the treatment plan. Option C does not provide reassurance to the client.

When using a Snellen alphabet chart, the nurse records the client's vision as 20/40. Which of the following statements best describes 20/40 vision? A. The client has alterations in near vision and is legally blind. B. The client can see at 20 feet what the person with normal vision can see at 40 feet. C. The client can see at 40 feet what the person with normal vision sees at 20 feet. D. The client has a 20% decrease in acuity in one eye, and a 40% decrease in the other eye.

Correct Answer: B The numerator refers to the client's vision while comparing the normal vision in the denominator.

Which of the following procedures or assessments must the nurse perform when preparing a client for eye surgery? A. Clipping the client's eyelashes B. Verifying the affected eye has been patched 24 hours before surgery C. Verifying the client has been NPO since midnight, or at least 8 hours before surgery. D. Obtaining informed consent with the client's signature and placing the forms on the chart.

Correct Answer: C Maintaining NPO status for at least 8 hours before surgical procedures prevents vomiting and aspiration. There is no need to patch an eye before most surgeries or to clip the eyelashes unless specifically ordered by the physician. The physician is responsible for obtaining informed consent; the nurse validates that the consent is obtained.

The client is being discharged from the ambulatory care unit following cataract removal. The nurse provides instructions regarding home care. Which of the following, if stated by the client, indicates an understanding of the instructions? A. "I will take Aspirin if I have any discomfort." B. "I will sleep on the side that I was operated on." C. "I will wear my eye shield at night and my glasses during the day." D. "I will not lift anything if it weighs more that 10 pounds."

Correct Answer: C The client is instructed to wear a metal or plastic shield to protect the eye from accidental and is instructed not to rub the eye. Glasses may be worn during the day. Aspirin or medications containing aspirin are not to be administered or taken by the client and the client is instructed to take acetaminophen as needed for pain. The client is instructed not to sleep on the side of the body on which the operation occurred. The client is not to lift more than 5 pounds.

When developing a teaching session on glaucoma for the community, which of the following statements would the nurse stress? A. Glaucoma is easily corrected with eyeglasses B. White and Asian individuals are at the highest risk for glaucoma. C. Yearly screening for people ages 20-40 years is recommended. D. Glaucoma can be painless and vision may be lost before the person is aware of a problem.

Correct Answer: D Open-angle glaucoma causes a painless increase in intraocular pressure (IOP) with loss of peripheral vision. A variety of miotics and agents to decrease IOP and occasional surgery are used to treat glaucoma. Blacks have a threefold greater chance of developing with an increased chance of blindness than other groups. Individuals older than 40 should be screened.

The client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. How does the nurse interpret these findings? A. The client can read at a distance of 60 feet what a client with normal vision can read at 20 feet. B. The client is legally blind. C. The client's vision is normal. D. The client can read at a distance of 20 feet what a client with normal vision can read at 60 feet.

D

The nurse is caring for a client who reports a recent change in smell and taste. Which action should the nurse take? A. Instruct the client to keep a food diary for one week. B. Encourage the client to add more seasonings to their food. C. Recommend the client stop taking all medications for a week then reintroduce them one at a time. D. Ask the client about any recent illnesses or injuries.

D

The nurse is observing a patient self-administer eye drops for the treatment of glaucoma. Which finding below requires you to re-educate the patient on how to administer eye drops correctly? A. The patient refrains from blinking after instilling the eye drops. B. The patient washes hands before and after administering the eye drops. C. The patient uses a tissue to catch any medication that drips out of the eye after administration of the drops. D. The patient places the drops of medication directly on the eye via the cornea.

D

Which condition may result in sensory alterations in an older adult? A. Constipation B. Anorexia C. Dry skin D. Presbycusis

D

A patient has been in contact isolation for 5 days because of a gastrointestinal infection. He has had few visitors and is unable to leave his room. His ability to ambulate continues to be very limited. Which nursing measures would assist in reducing the risk of sensory deprivation? Select All That Apply A. Arrange for him to have a roommate. B. Turn off the lights and close the window blinds. C. Arrange for peacefulness and frequent rest periods. D. Assist him out of bed and provide reading materials. E. Provide meaningful interaction and stimulation.

D,E