Chapter 49 Notes

The home care nurse is instructing a nursing assistant about interventions to facilitate location of items for patients with vision impairment. Which strategy is not effective in enhancing a patient's impaired vision? 1 Use of fluorescent lighting 2 Use of warm incandescent lighting 3 Use of colors with sharp contrast and intensity 4 Use of yellow or amber lenses to decrease glare

1 Use of fluorescent lighting

When assessing a 45-year-old patient's sensory status, which of the following assessment findings does the nurse consider a normal part of aging? 1 Presbyopia and the need for glasses for reading 2 Reduced sensitivity to odors 3 Impaired balance and coordination 4 Reduced taste discrimination

1 Presbyopia and the need for glasses for reading

The medical record of an older adult reveals a stroke affecting the right hemisphere of the brain. Which of these assessment findings should the nurse expect to find? (Select all that apply.) 1 Visual spatial alterations such as loss of half of a visual field 2 Loss of sensation and motor function on the right side of the body 3 Inattention and neglect, especially to the left side 4 Cloudy or opaque areas in part of the lens or the entire lens

1 Visual spatial alterations such as loss of half of a visual field 3 Inattention and neglect, especially to the left side

Which patient is most likely to experience sensory deprivation? 1 A 79-year-old visually impaired resident of a nursing home who enjoys taking part in different hobbies and activities 2 A 14-year-old girl isolated in the hospital because of severe immune system suppression 3 A hearing-impaired 66-year-old woman who lives in an assisted-living facility 4 A 9-year-old boy who is deaf and uses sign language to communicate with his friends, family, and teachers

2 A 14-year-old girl isolated in the hospital because of severe immune system suppression

A 74-year-old patient who has returned to the nursing home following surgical removal of bilateral cataracts reports feeling a little uncertain about walking by herself. Which of the following approaches do you use to assist her with ambulation? 1 Walk one-half step behind and slightly to her side. 2 Have her grasp your arm just above the elbow and walk at a comfortable pace, warning her when you approach obstacles. 3 Allow her to stand alone in unfamiliar areas to encourage confidence building. 4 If she requires assistance, place your hand around her waist.

2 Have her grasp your arm just above the elbow and walk at a comfortable pace, warning her when you approach obstacles.

A patient with a history of a hearing deficit comes to the medical clinic for a routine checkup. His wife died 2 years ago, and he admits to feeling lonely much of the time. Interventions the nurse uses to reduce loneliness include: (Select all that apply.) 1 Reassuring the patient that loneliness is a normal part of aging. 2 Providing information about local social groups in the patient's neighborhood. 3 Maintaining distance while talking to avoid overstimulating the patient. 4 Recommending that the patient consider making living arrangements that will put him closer to family or friends.

2 Providing information about local social groups in the patient's neighborhood. 4 Recommending that the patient consider making living arrangements that will put him closer to family or friends.

The nurse completes an assessment of a 67-year-old female patient who comes to the clinic for the first time. During the examination the patient's temperature is 99.6° F (37.6° C), heart rate 80 beats/min, respiratory rate 18 breaths/min, and blood pressure 142/84 mm Hg. She is not attentive as the nurse asks questions. At one point, she shouts answers to questions about her diet. However, as the nurse speaks, the patient consistently smiles and nods in agreement. The nurse's assessment indicates: 1 A visual deficit. 2 Patient is normal. 3 A hearing deficit. 4 Sensory overload.

3 A hearing deficit.

A 72-year-old patient with bilateral hearing loss wears a hearing aid in her left ear. Which of the following approaches best facilitate communication with her? 1 Speak directly into the patient's left ear. 2 Approach the patient from behind and speak frequently. 3 Face the patient when speaking; speak slower and in a normal volume. 4 Face the patient when speaking; use a louder than normal tone of voice.

3 Face the patient when speaking; speak slower and in a normal volume.

A nurse is performing an assessment on a patient admitted to the emergency department with eye trauma. The nurse's priority interventions include which of the following? (Select all that apply.) 1 Conducting a home safety assessment and identifying hazards in the patient's living environment 2 Reinforcing eye safety at work and in activities that place the patient at risk for eye injury 3 Placing necessary objects such as the call light and water in front of the patient to prevent falls due to reaching 4 Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye

3 Placing necessary objects such as the call light and water in front of the patient to prevent falls due to reaching 4 Orienting the patient to the environment to reduce anxiety and prevent further injury to the eye

The nurse is conducting discharge teaching for a patient with diminished tactile sensation. Which of the following statements by the patient would indicate that additional teaching is needed? 1 "I am at risk for injury from temperature extremes." 2 "I may be able to dress more easily with zippers or pullover sweaters." 3 "A home care referral may help me achieve a maximum degree of independence." 4 "I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first."

4 "I have right-sided partial paralysis and reduced sensation, so I should dress the left side of my body first."

A patient has been on contact isolation for 4 days because of a gastrointestinal infection. He has had few visitors and few opportunities to leave his room. His ambulation is also still limited. Nursing measures to reduce sensory deprivation include: (Select all that apply.) 1 Arranging for him to have a roommate. 2 Turning off the lights and closing the room drapes. 3 Arranging for peacefulness and frequent rest periods. 4 Helping him to a chair or bringing a flower into the room. 5 Sitting down, speaking, touching, and listening to his feelings and perceptions.

4 Helping him to a chair or bringing a flower into the room. 5 Sitting down, speaking, touching, and listening to his feelings and perceptions.

Because hearing impairment is one of the most common disabilities among children, a health promotion intervention is to teach parents and children to: 1 Avoid activities in which there may be crowds. 2 Delay childhood immunizations until hearing can be verified. 3 Prophylactically administer antibiotics to reduce the incidence of infections. 4 Take precautions when involved in activities associated with high-intensity noises.

4 Take precautions when involved in activities associated with high-intensity noises.

When communicating with a patient who has expressive aphasia, the highest priority for the nurse is: 1 To ask open-ended questions. 2 To understand that the patient will be uncooperative. 3 To coach the patient to respond. 4 To offer pictures or a communication board so the patient can point.

4 To offer pictures or a communication board so the patient can point.

A nurse is performing a home care assessment on a patient with a hearing impairment. The patient reports, "I think my hearing aid is broken. I can't hear anything." Which of the following teaching strategies should not be implemented? 1 Demonstrating hearing aid battery replacement 2 Reviewing method to check volume on hearing aid 3 Discussing measures for cleaning battery 4 Turning dial to minimum setting and, in a louder-than-normal voice, asking the patient, "Is this voice clear?"

4 Turning dial to minimum setting and, in a louder-than-normal voice, asking the patient, "Is this voice clear?"

The nurse is caring for an older patient with glaucoma. When developing a discharge plan, which of the priority interventions enables the patient to function safely with existing deficits and continue a normal lifestyle? 1 Encourage the patient's family to visit him or her once a month. 2 Suggest to the patient that he or she consider moving to a long-term care facility. 3 Say nothing because it is most appropriate that the patient identify personal interventions to compensate for a sensory alteration. 4 Work closely with the patient to identify ways to modify his or her home environment and refer to appropriate community-based resources.

4 Work closely with the patient to identify ways to modify his or her home environment and refer to appropriate community-based resources.