Sensory Perception

After a hurricane, the nurse is assessing the response of a client to stimuli on the Glasgow Coma Scale (GCS) as a part of the primary survey. The nurse observes that the client opens his eyes when his name is stated, uses disorganized words, and is unable to follow commands, but attempts to remove the offending stimulus. What is the Glasgow coma score for this client? Record your answer using a whole number.____________

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A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply. 1 Cool skin 2 Photophobia 3 Constipation 4 Periorbital edema 5 Decreased appetite

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A couple arrives at the mental health clinic for counseling because the husband consistently believes that his wife is having multiple affairs. After several sessions a delusional disorder is diagnosed. What specific subtype of the delusion does the nurse identify? 1 Jealousy 2 Somatic 3 Grandiose 4 Persecutory

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A child visits the pediatric clinic for a 6-week checkup after an adenoidectomy. Which of the child's abilities should the nurse evaluate? 1 Hearing 2 Swallowing 3 Speaking clearly 4 Coughing voluntarily

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A nurse is assessing a client who was admitted with a head injury that occurred 4 days ago and is diagnosed with an injury to the speech center in the cerebral cortex. Upon further assessment, the nurse finds that the client is unable to understand written or verbal speech. Which condition does the nurse suspect? 1 Aphasia 2 Dysarthria 3 Borborygmi 4 Tactile fremitus

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The nurse is preparing to administer ear drops to a client who has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. 1 Allergy to the medication 2 Itching in the ear canal 3 Drainage from the ear canal 4 Tympanic membrane rupture 5 Partial hearing loss in the affected ear

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The nurse is communicating with an older adult who has a hearing disability. Which intervention by the nurse is beneficial to promote communication? Select all that apply. 1 Giving the client a chance to speak 2 Assuming the client is being uncooperative 3 Chewing gum while talking to the client 4 Making sure that the client knows you are speaking 5 Keeping the communication concise

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A client is being evaluated based on client reports of an impairment of a portion of the peripheral vision. After testing is completed, a diagnosis of retinal detachment is made, and a cryosurgical procedure is scheduled. As part of the preoperative teaching, the nurse provides information about what the client can expect and includes which information? 1 An explanation that the surgery will be brief 2 A description of the surgical suite environment 3 The procedure and risks of the repair of the retina 4 The importance of postoperative coughing and deep-breathing exercises

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A healthcare provider recently made the diagnosis that a client has glaucoma. The nurse is preparing to administer eyedrops to the client. Which ophthalmic solution is contraindicated for this client? 1 Timolol 2 Atropine 3 Pilocarpine 4 Epinephrine

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A male client in a mental health facility turns his head to the side during a unit meeting as if he hears something. When the nurse comments about it, the client replies, "You know, it's that microcomputer those foreign agents implanted in my ear." In light of this statement, what does the nurse determine that the client is experiencing? 1 Illusions 2 Delusional thoughts 3 Neologistic thinking 4 Disorganized cognition

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A client with a cerebrovascular accident ("brain attack") has dysarthria. What should the nurse include in the plan of care to address this problem? 1 Routine hygiene 2 Liquid formula diet 3 Prevention of aspiration 4 Effective communication

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A nurse administers carbidopa-levodopa to a client with Parkinson disease. Which therapeutic effect does the nurse expect the medication to produce? 1 Increase in acetylcholine production 2 Regeneration of injured thalamic cells 3 Improvement in myelination of neurons 4 Replacement of a neurotransmitter in the brain

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A client who is exposed to pollens reports a runny, stuffy nose and itchy, watery eyes. The nasal examination reveals swollen and pink nasal mucosa. Which finding does the nurse suspect to be present in the client's laboratory reports? 1 Immunoglobulin E (IgE) level of 150 IU/mL 2 Eosinophil count of 2% 3 Percentage of neutrophils of 80% 4 Total white blood cell (WBC) count of 3 billion cells/L

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A client with a cervical injury reports a severe headache and nasal congestion. What should the nurse assess for? 1 Suprapubic distention 2 Increased spinal reflexes 3 Adventitious breath sounds 4 Imminent development of shock

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An adolescent arrives at the clinic reporting buzzing in the ears. What assessment data are essential for the nurse to obtain? 1 Music preferences 2 Childhood ear infections 3 Recent emotional trauma 4 Familial history of deafness

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Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? 1 Chlorothiazide 2 Acetazolamide 3 Methazolamide 4 Aclidinium bromide

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When planning activities for a child with autism, what does the nurse remember that autistic children respond best to? 1 Loud, cheerful music 2 Large-group activities 3 Individuals in small groups 4 Their own self-stimulating acts

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While conducting a health interview with a client who has human immunodeficiency virus, the nurse inquires about papilledema and the presence of exudates. Which body system may the nurse be assessing? 1 Ocular 2 Respiratory 3 Neurological 4 Cardiovascular

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A hospitalized client hurriedly approaches the nurse, saying that it sounds like there is a roaring fire in the bathroom. In reality, the client's roommate has just turned the shower on full force. What term best describes this experience? 1 Illusion 2 Delusion 3 Dissociation 4 Hallucination

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Before performing a visual system assessment, the nurse observes that the client is dressed in an unusual color combination of clothes. The client's eye examination reveals changes in the retina. Which condition might this client have? 1 Decrease in cones 2 Retinal vascular changes 3 Overall loss of photoreceptor cells 4 Macular degeneration of the retina

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While assessing a pediatric client, an ophthalmologist notices that the child is unable to focus on an object with both eyes simultaneously. Which other findings in the client confirms the diagnosis as strabismus? Select all that apply. 1 Impaired near vision 2 Crossed appearance of eyes 3 Elevated intraocular pressure 4 Impaired extraocular muscles 5 Degeneration of central retina

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Which physiologic responses should a nurse expect when assessing a client with hyperthyroidism? Select all that apply. 1 Bradycardia 2 Blurred vision 3 Cold intolerance 4 Increased appetite 5 Widened pulse pressure

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Which cranial nerves assist with both sensory and motor functioning in a client? Select all that apply. 1 Optic 2 Facial 3 Trochlear 4 Accessory 5 Trigeminal

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A nurse is reviewing the laboratory report for a client who is undergoing drug therapy for acne and finds a serum cholesterol concentration of 215 mg/dL. Which medication used by the client may have caused this condition? 1 Tretinoin 2 Tazarotene 3 Isotretinoin 4 Benzoyl peroxide

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A client is admitted to the hospital with a tentative diagnosis of urinary retention related to benign prostatic hyperplasia. The primary healthcare provider notes a secondary diagnosis of delirium related to urosepsis and prescribes the insertion of an indwelling urinary retention catheter. Which nursing action is most important at this time? 1 Secure a prescription for wrist restraints. 2 Orient the client to time, place, and person. 3 Involve family members in the client's care. 4 Determine whether any unsafe behavior patterns exist.

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A client underwent an external ear assessment and is diagnosed with hard nodules on the pinna. Which assessment finding indicates tophi? 1 Ulcerative lesions at the site 2 Crusted indurated lesions at the site 3 Decreased calcium levels in the blood 4 Increased uric acid levels in the blood

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