Sensory Perception

Parents of a 3-week-old healthy newborn ask the nurse why their daughter is intermittenly cross-eyed. The nurse's best response is:

"It is normal to have eye crossing in the newborn period."

The family of an intensive care unit (ICU) client, who cannot be roused and does not respond to stimuli, asks the nurse how they should communicate with the client. Which of the following should the nurse recommend?

"Speak to the client as they are likely to hear what is being said, even if there is no response."

When developing a teaching plan for a patient scheduled for ambulatory surgery with epidural anesthesia, which of the following would the nurse include?

"You shouldn't experience a headache after this type of anesthesia."

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve?

Acoustic

Which of the following clinical manifestations of type 2 diabetes occurs if glucose levels are very high?

Blurred vision

Which of the following is an indicator of neurovascular compromise?

Capillary refill of more than 3 seconds

Which common problem of the upper extremity results from entrapment of the median nerve at the wrist?

Carpal tunnel syndrome

The nurse identifies the pain described by a client whose back discomfort began after an automobile accident and has persisted for 8 months as

Chronic

The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from social work or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship?

Communication barriers between the mother and staff

A client suffering from infectious diarrhea, dehydration, and right sided paralysis is confined to bed. What is the client most prone to?

Decubitus ulcer

Which of the following terms refers to altered sensation of orientation in space?

Dizziness Explanation: Dizziness may be associated with inner ear disturbances. Vertigo is the illusion of movement where the individual or the surroundings are sensed as moving. Tinnitus refers to a subjective perception of sound with internal origin. Nystagmus refers to involuntary rhythmic eye movement

Which of the following is an example of a topical anesthetic?

EMLA cream Explanation: EMLA cream is a topical anesthetic. Bacitracin, Silvadene, and Garamycin are topical antibiotics.

Which nerve is implicated in the Chvostek's sign?

Facial

Bell's palsy is a paralysis of which of the following cranial nerves?

Facial Explanation: Bell's palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve, which results in weakness or paralysis of the facial muscles on the ipsilateral, or same side, of the affected facial nerve. Trigeminal neuralgia is a paralysis of the trigeminal nerve (cranial nerve V). The optic nerve (cranial nerve II) functions in vision. The vestibulocochlear nerve (cranial nerve VIII) functions in hearing

People with hyperopia are considered which of the following?

Farsighted

Which disturbance results in loss of half of the visual field?

Homonymous hemianopsia Explanation: Homonymous hemianopsia (loss of half of the visual field) may occur from stroke and may be temporary or permanent. Double vision is documented as diplopia. Nystagmus is ocular bobbing and may be seen in multiple sclerosis. Anisocoria is unequal pupils.

A patient informs the nurse that she is not able to recall her phone number or address, and this is concerning to the patient. The nurse recognizes that the inability to recall information is indicative of which sensory/perception problem?

Impaired memory

Assessment of visual acuity reveals that the client has blurred vision when looking at distant objects but no difficulty seeing near objects. The nurse documents this as which of the following?

Myopia

A client who is blind is hospitalized for hip surgery. The nurse notices that the containers on the client's lunch tray are unopened, the client is fumbling with items, and food is on the front of the client's gown. The nurse assists the client by

Opening containers and orienting the client to placement of items on the tray

The nurse determines that when a female client who underwent a mammogram earlier in the day is asked to have a breast ultrasound and is informed that she demonstrates signs of breast malignancy, the client is at risk for experiencing sensory

Overload

Which nerve is being assessed when the nurses asks the patient to dorsiflex his ankle and extend his toes?

Peroneal

The nurse is caring for a patient who communicates via sign language. To promote communication, the nurse should do which of the following?

Provide a sign language interpreter.

The nurse teaches the patient that corticosteroids will be used to treat his brain tumor for which reason?

Reduce cerebral edema

The nurse is taking a rectal temperature on a patient who reports feeling light-headed during the procedure. What would be the nurse's priority action in this situation?

Remove the thermometer and assess the blood pressure and heart rate.

An 11-year-old child is sent to the school nurse reporting difficulty reading the blackboard in the classroom. The nurse assesses that the child does not have difficulty reading a laptop screen or reading books. What is the best action by the nurse?

Request that the child be screened for myopia.

A special needs child has been placed in a classroom with other special needs children. The classroom is noisy with a high level of activity, and the child appears to have difficulty concentrating on his work. What is the child likely experiencing?

Sensory overload

A patient has expressed great relief at the improvement in her hearing after irrigation of her ear canal yielded a large amount of impacted cerumen. This patient was experiencing a sensory alteration related to which of the following?

Sensory reception

A client has a herniated disk in the region of the third and fourth lumbar vertebrae. Which nursing assessment finding most supports this diagnosis?

Severe lower back pain

Which of the following is a symptom related to vertigo?

Spinning sensation

You are the nurse providing prenatal education to a group of pregnant teenagers. One of the group members asks you to talk about how the baby develops soon after birth. An accurate statement from you about neonatal development would be which of the following?

The neonate is able to hear and turn toward sound

A nurse is performing eye assessments at a community clinic. Which assessment would the nurse document as normal?

The patient's pupils are black, equal in size, and round and smooth.

The nurse is assessing the ear canal and tympanic membrane of a patient using an otoscope. Which finding would the nurse document as normal?

The tympanic membrane is translucent, shiny, and gray.

You are caring for a female patient who is unconscious. You should pay special attention to cleaning which of the following areas of the body?

Underneath the breasts and in between skin folds

Which of the following manifestations is the most problematic for the patient diagnosed with Meniere's disease?

Vertigo

Mark is a 20-year-old college student who has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is Mark most likely experiencing?

Visceral pain

Sensorineural hearing loss results from which condition?

damage to the cochlear or vestibulocochlear nerve

A patient with uncontrolled hypertension experienced a stroke 1 week ago, leading to significant motor losses. A successful and normal adaptive response to these new limitations is evident if the patient:

exhibits signs of grief.

The client arrives in the emergency department following a bicycle accident in which the client's forehead hit the pavement. The client is diagnosed as having a hyphema. The nurse should place the client in which position?

semi-Folwer's

A nurse providing hygiene and bathing for older adult clients knows that additional safety measures may be necessary in their care. When delegating care to an Unlicensed Assistive Personnel (UAP), the nurse explains that the following are true regarding safety of the older adult while bathing. Select all that apply.

• Use of a tub/shower seat may be necessary if balance problems are present. • Water temperature should be monitored carefully due to decreased temperature sensation. • Using a long-handled shower brush or attachment helps with limited mobility.