Sensory Perception Test 4 PrepU

A client with a sports injury undergoes a diagnostic arthroscopy of the left knee. What comment by the client following the procedure will the nurse address first? A. "My knee aches." B. "My foot is swollen." C. "My feet are cold." D. "My toes are numb."

"My toes are numb." Numbness would indicate neurological compromise of the extremity and requires immediate intervention to prevent permanent damage. An aching knee is expected after the procedure. Cold or swollen feet are not priority assessments.

The nurse in an obstetric clinic is conducting client education with a group of expectant mothers. One young woman asks the nurse to tell the group what labor pain is like. What would be the nurse's best response? A. "It has been described as the worst pain you will ever feel." B. "The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in." C. "It is best evaluated by talking with visitors in the labor room because they know you best." D. "It comes in waves."

"The pain of labor is unique and multidimensional. It originates from different places depending on what stage of labor you are in." Pain sensations associated with labor originate from different places, depending on the stage of labor.

A nurse is providing care to a preterm neonate. Which interventions would be most effective in minimizing the newborn's pain? Select all that apply. A. encouraging kangaroo care during procedures B. covering the newborn loosely with a blanket C. removing tape gently from the skin D. using a colorful mobile for distraction E. using cool blankets to soothe the newborn F. increasing the volume on device alarms

A. encouraging kangaroo care during procedures C. removing tape gently from the skin D. using a colorful mobile for distraction Interventions to reduce pain in the preterm newborn include swaddling the newborn closely to establish physical boundaries, using gentle handling, rocking, caressing, and cuddling, encouraging kangaroo care during procedures, and offering a pacifier for nonnutritive sucking prior to a procedure. Tape should be used minimally and should be removed gently to prevent skin tearing. Environmental stimuli need to be reduced, such as by turning down the volumes on alarms. Warm rather than cool blankets facilitate relaxation. Distraction using colorful mobiles or objects also can be effective.

The nurse is completing a neurological assessment and uses the whisper test to assess which cranial nerve? A. Vagus B. Facial C. Olfactory D. Acoustic

Acoustic Clinical examination of the acoustic nerve can be done by the whisper test. Having the client say "ah" tests the vagus nerve. Observing for symmetry when the client performs facial movements tests the facial nerve. The olfactory nerve is tested by having the client identify specific odors.

A major role for nursing in the management of glaucoma is health education. Which of the following is the most important teaching point that the nurse should advise the patient of? A. Participate in the decision-making process. B. Keep all follow-up appointments. C. Adhere to the medication regimen. D. Keep a record of eye pressure measurements.

Adhere to the medication regimen. All of the teaching points are important but the most important is emphasizing the strict adherence to the medication regimen because glaucoma cannot be cured but its progression can be slowed.

A client is experiencing muscle weakness in the upper extremities. The client raises an arm above the head but then loses the ability to maintain the position. Muscular dystrophy is suspected. Which diagnostic test would evaluate muscle weakness or deterioration? A. A serum calcium test B. A magnetic resonance imaging (MRI) C. An electromyography D. An arthroscopy

An electromyography An electromyography tests the electrical potential of muscles and nerves leading to the muscles. It is done to evaluate muscle weakness or deterioration. A serum calcium test evaluates the calcium in the blood. An arthroscopy assesses changes in the joint. An MRI identifies abnormalities in the targeted area.

The nurse is caring for Jana Wok, a 23-year-old patient who suffered a traumatic brain injury in a motor vehicle accident. Jana requires mechanical ventilation, cannot be aroused, and displays no response to painful stimuli. The nurse documents that Jana's level of consciousness is which of the following? A. Coma B. Somnolence C. Stupor D. Asleep

Coma A person in a coma cannot be aroused and does not respond to stimuli. When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. Somnolence (alternatively "sleepiness" or "drowsiness") is a state of strong desire for sleep.

Audiometry confirms a client's chronic progressive hearing loss. Further investigation reveals ankylosis of the stapes in the oval window, a condition that prevents sound transmission. This type of hearing loss is called A. fluctuating hearing loss. B. functional hearing loss. C. conductive hearing loss. D. sensorineural hearing loss.

Conductive hearing loss. Conductive hearing loss results from interference with the conduction of sound waves (sound transmission) from the tympanic membrane to the inner ear. The stapes must move freely for sound to be transmitted. Bone tissue overgrowth causes the stapes to become fixed or immobile (ankylosed) in the oval window, preventing sound transmission. In a functional hearing loss, no organic lesion is found. Fluctuating hearing loss is a form of sensorineural hearing loss that varies over time. Sensorineural hearing loss affects the inner ear and involves the cochlea and eighth cranial nerve.

Which nursing suggestion would be most helpful to the client with recurrent otitis externa? A. Place ear plugs into the ears before swimming B. Avoid lying on the side of the affected ear C. Use a cotton applicator to ensure that the ear canal is dry. D. Flush the ear with hydrogen peroxide

Place ear plugs into the ears before swimming The nurse instructs the client to carry out the medical treatment and provides health teaching to prevent recurrence. For example, he or she advises swimmers to wear soft plastic ear plugs to prevent trapping water in the ear. A cotton tip applicator should not be placed into the ear canal because it could perforate the eardrum. Above all, the nurse advises the client to avoid the use of nonprescription remedies unless they have been approved by the physician and to contact the physician if symptoms are not relieved in a few days.

The nurse is instructing the client with dried cerumen blocking the ear canal on potential methods to reduce symptoms. Which at-home methods of cerumen removal are discouraged? A. Instilling 1 to 2 drops of half-strength peroxide in the ear B. Irrigating the ear with warm water and a rubber-bulb syringe C. Removing the cerumen by means of a cotton tip applicator D. Using warm glycerin or mineral oil to soften the cerumen

Removing the cerumen by means of a cotton tip applicator The nurse is an important resource person to consult when a client has an issue with the ear structure or hearing. The nurse is correct to discourage placing anything down the ear canal that could push the cerumen deeper toward or puncture the tympanic membrane. The other options are appropriate to soften and lubricate the cerumen or to irrigate the cerumen from the ear.

A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms? A. Serum calcium level of 8.9 mg/dl B. Serum glucose level of 450 mg/dl C. Serum calcium level of 10.2 mg/dl D. Serum glucose level of 52 mg/dl

Serum glucose level of 52 mg/dl Headache, sweating, tremor, pallor, and nervousness typically result from hypoglycemia, an insulin reaction in which serum glucose level drops below 70 mg/dl. Hypoglycemia may occur 4 to 18 hours after administration of isophane insulin suspension or insulin zinc suspension (Lente), which are intermediate-acting insulins. Although hypoglycemia may occur at any time, it usually precedes meals. Hyperglycemia, in which serum glucose level is above 180 mg/dl, causes such early manifestations as fatigue, malaise, drowsiness, polyuria, and polydipsia. A serum calcium level of 8.9 mg/dl or 10.2 mg/dl is within normal range and wouldn't cause the client's symptoms.

A nurse is caring for Jeff, a 13-year-old boy who has suffered a concussion while playing hockey. The morning assessment finds him very drowsy but he responds normally to stimuli. What does the nurse document as his level of consciousness? A. Somnolence B. Asleep C. Stupor D. Coma

Somnolence When a person is asleep he/she can be aroused by normal stimuli (light touch, sound, etc.). When someone is stuporous, he/she can be aroused by extreme and/or repeated stimuli. A person in a coma cannot be aroused and does not respond to stimuli. Someone who somnolent is extremely drowsy, but will respond normally to stimuli.

Nursing assessment findings reveal that the client is afraid of dying during the surgical procedure. Which surgical team member would be most helpful in addressing the client's concern? A. Registered nurse first assistant B. Anesthesiologist C. Surgeon D. Circulating nurse

Surgeon It is the surgeon's responsibility to explain the benefits, alternatives, possible risks, complications, disfigurement, disability, and removal of body parts in obtaining informed consent from the client.

A client periodically has acute panic attacks. These attacks are unpredictable and have no apparent association with a specific object or situation. During an acute panic attack, the client may experience: A. a decreased heart rate. B. a decreased perceptual field. C. heightened concentration. D. a decreased respiratory rate.

a decreased perceptual field. Panic is the most severe level of anxiety. During a panic attack, a client's perceptual field, narrows. The client becomes more self-focused, less aware of surroundings, and unable to process information from the environment. The client's decreased perceptual field impairs attention and ability to concentrate. During an acute panic attack, the client may experience an increase, not a decrease, in heart and respiratory rates, resulting from stimulation of the sympathetic nervous system.

The nurse is conducting an assessment of an elderly client who is blind. What would the nurse expect to be present in the client's medical history? A. cerebrovascular accident B. systemic lupus erythematosus C. diabetes mellitus D. cancer

diabetes mellitus Type 2 diabetes is very prevalent, especially in the elderly. Diabetic retinopathy is the primary cause of blindness through destruction of retinal blood vessels. The other conditions, while they may be associated with blindness, are not common causes of blindness.

A client tells the health care provider he has noticed a recent change in his vision: he can bring distant images into focus, but near images become blurred. The client has most likely developed: A. hyperopia. B. myopia. C. astigmatism. D. nearsightedness.

hyperopia. Hyperopia or farsightedness occurs when the accommodative changes of the lens can bring distant images into focus, but near images become blurred. Persons with myopia or nearsightedness can see close objects without a problem because accommodative changes in their lens bring near objects into focus, but distant objects are blurred. Astigmatism is a refractive defect of the corneal surface.

A nurse is working on a surgical floor. The nurse must logroll a client following a: A. hemorrhoidectomy. B. cystectomy. C. laminectomy. D. thoracotomy.

laminectomy. The client who has had spinal surgery, such as laminectomy, must be logrolled to keep the spinal column straight when turning. The client who has had a thoracotomy or cystectomy may turn himself or may be assisted into a comfortable position. Under normal circumstances, hemorrhoidectomy is an outpatient procedure, and the client may resume normal activities immediately after surgery.

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which of the following questions should she ask? A. "Do you have diabetes?" B. "Do you live by yourself?" C. "Do you work around loud noises at work?" D. "Are you receiving chemotherapy?"

"Do you work around loud noises at work?" Clients may be at risk for sensory disturbances for different reasons. Lifestyle factors include work or leisure activities that are potentially harmful to the eyes and ears, such as loud noises. Physiologic factors, such as diabetes and use of medications (chemotherapy), place clients at risk for sensory disturbances as well. Social and environmental factors include human and environmental stimulation (living by oneself).

The nurse is assisting with administering a Tensilon test to a patient with ptosis. If the test is positive for myasthenia gravis, what outcome does the nurse know will occur? A. Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms. B. After administration of the medication, there will be no change in the status of the ptosis or facial weakness. C. Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. D. The patient will have recovery of symptoms for at least 24 hours after the administration of the Tensilon.

Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes. Thirty seconds after injection, facial muscle weakness and ptosis should resolve for about 5 minutes (Hickey, 2009). Immediate improvement in muscle strength after administration of this agent represents a positive test and usually confirms the diagnosis.

A nurse is caring for a client who is nursing her baby boy. The client reports afterpains. Secretion of which substance would the nurse identify as the cause of afterpains? A. prolactin B. progesterone C. estrogen D. oxytocin

oxytocin Secretion of oxytocin stimulates uterine contraction and causes the woman to experience afterpains. Decrease in progesterone and estrogen after placental delivery stimulates the anterior pituitary to secrete prolactin which causes lactation.

The daughter of a patient with Huntington's disease asks the nurse what the risk is of her inheriting the disease. What is the best response by the nurse? A. "If one parent has the disorder, there is an 75% chance that you will inherit the disease." B. "The disease is not hereditary and therefore there is no risk to you." C. "The disease is inherited and all offspring of a parent will develop the disease." D. "If one parent has the disorder, there is a 50% chance that you will inherit the disease."

"If one parent has the disorder, there is a 50% chance that you will inherit the disease." Huntington disease is a chronic, progressive, hereditary disease of the nervous system that results in progressive involuntary choreiform movement and dementia. The disease affects approximately 1 in 10,000 men or women of all races at midlife. It is transmitted as an autosomal dominant genetic disorder; therefore, each child of a parent with Huntington disease has a 50% risk of inheriting the disorder (Ha & Fung, 2012).

The nurse is instructing a client's family members on the most incapacitating symptom of Ménière's disease. Which nursing instruction associated with the symptom is most helpful? A. Ensure low lighting in the room. B. Assist the client when ambulating. C. Sit in front of the client when speaking. D. Keep a bucket beside the bed.

Assist the client when ambulating. The most incapacitating symptom of Ménière's disease is vertigo. When the client is experiencing vertigo or dizziness, the gate is unsteady. Having a person assist the client when ambulating is most helpful in preventing falls. Keeping a bucket at the bedside is helpful if the client is experiencing nausea. Photophobia is not a main symptom of Ménière's disease. If the client experiences hearing loss, being able to see the client's lips may be helpful.

An adolescent patient comes to the clinic with complaints of "terrible pain" during menstruation. What should the nurse document this subjective data as? A. Metrorrhagia B. Amenorrhea C. Menorrhagia D. Dysmenorrhea

Dysmenorrhea Primary dysmenorrhea is painful menstruation, with no identifiable pelvic pathology. It occurs at the time of menarche or shortly thereafter. It is characterized by crampy pain that begins before or shortly after the onset of menstrual flow and continues for 48 to 72 hours. Amenorrhea is the absence of menstruation. Menorrhagia is prolonged or excessive bleeding at the time of the regular menstrual flow. Metrorrhagia is vaginal bleeding between regular menstrual periods.

The nurse assesses that her client has olfactory disturbances. Which of the following health topics would be important to teach the client? A. Practicing oral care three times a day B. Eliminating disturbing odors with adequate ventilation C. Protecting the skin from extremes in temperature D. Using earplugs when using loud machinery

Eliminating disturbing odors with adequate ventilation Olfactory or smell disturbances can be aided by eliminating disturbing odors with adequate ventilation. Earplugs help those with auditory disturbances. Oral care is useful for those with taste disturbances. Protecting the skin is important for those with tactile disturbances.

The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences? A. Descent of fetus into birth canal B. Stretching of cervix C. Pressure in the perineum D. Fear of pain during labor

Fear of pain during labor Fear of pain during labor is a psychosocial factor. The stretching of the cervix, descent of the fetus into the birth canal, and pressure on the perineum are physical factors.

A client reports pain in the lower back, hips, and joints 10 days after the birth of her baby. What instruction should the nurse give the client after birth to prevent low back pain and injury to the joints? A. Maintain correct posture and positioning. B. Soak in a warm bath several times a day. C. Apply ice to the sore joints. D. Try to avoid carrying the baby for a few days.

Maintain correct posture and positioning. The nurse should recommend that clients maintain correct position and good body mechanics to prevent pain in the lower back, hips, and joints. Avoiding carrying her baby and soaking several times per day is unrealistic. Application of ice is suggested to help relieve breast engorgement in nonbreastfeeding clients.

The nurse is performing an assessment of the visual fields for a patient with glaucoma. When assessing the visual fields in acute glaucoma, what would the nurse expect to find? A. Watery ocular discharge B. Clear cornea C. Marked blurring of vision D. Constricted pupil

Marked blurring of vision Glaucoma is often called the "silent thief of sight" because most patients are unaware that they have the disease until they have experienced visual changes and vision loss. The patient may not seek health care until he or she experiences blurred vision or "halos" around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision, aching or discomfort around the eyes, and headache.

The nurse is assisting the eye surgeon in completing an examination of the eye. Which piece of equipment would the nurse provide to the physician to examine the optic disc under magnification? A. Ophthalmoscope B. Retinoscope C. Tonometer D. Amsler grid

Ophthalmoscope The nurse is correct to provide an ophthalmoscope to the surgeon for examination of theoptic disc. A retinoscope is used to determine errors in refraction. A tonometer measures intraocular pressure. An Amsler grid tests for problems with the macula.

The pre-nursing class is learning about the nervous system in their anatomy class. What part of the nervous system would the students learn is responsible for digesting food and eliminating body waste? A. Central B. Peripheral C. Parasympathetic D. Sympathetic

Parasympathetic The parasympathetic division of the autonomic nervous system works to conserve body energy and is partly responsible for slowing heart rate, digesting food, and eliminating body wastes.

Which terms refers to the progressive hearing loss associated with aging? A. Presbycusis B. Exostoses C. Sensorineural hearing loss D. Otalgia

Presbycusis Age-related changes of both the middle and inner ear result in hearing loss. Exostoses refer to small, hard, bony protrusions in the lower posterior bony portion of the ear canal. Otalgia refers to a sensation of fullness or pain in the ear. Sensorineural hearing loss is loss of hearing related to damage of the end organ for hearing and/or cranial nerve VIII.

An aging client is brought to the eye clinic by the son. The son states he has seen his parent holding reading materials at an increasing distance to focus properly. What age-related changes does this indicate? A. Cataract B. Macular degeneration C. Presbyopia D. Myopia

Presbyopia Refractive changes, such as presbyopia, occur in older adults where the lens cannot readily accommodate aging. In such cases, the client is observed holding reading materials at an increasing distance to focus properly. In case of a cataract, the client should report increased glare, decreased vision, and changes in color perception. Macular degeneration affects the central vision. Myopia is the inability to see things at a distance clearly.

The home health nurse reviews a medication administration calendar with an elderly patient. In order to consider sensory changes that occur with aging, how should the nurse proceed? A. Print directions in large, bold type, preferably using black ink. B. Highlight or shade important dates and times with contrasting colors. C. Type out the information on the computer. D. Use several different colors to emphasize special dates.

Print directions in large, bold type, preferably using black ink. Older adults frequently have one or more chronic illnesses that are managed with numerous medications and complicated by periodic acute episodes. Older adults may also have other problems that affect adherence to therapeutic regimens, such as increased sensitivity to medications and their side effects, difficulty in adjusting to change and stress, financial constraints, forgetfulness, inadequate support systems, lifetime habits of self-treatment with over-the-counter medications, visual and hearing impairments, and mobility limitations. To promote adherence among older adults, all variables that may affect health behavior should be assessed

The nurse is caring for a client who communicates via sign language. What should the nurse do to promote communication? A. Direct conversation to a family member. B. Communicate only in written format. C. Provide a sign language interpreter. D. Ask a family member to act as interpreter.

Provide a sign language interpreter. Communication strategies to ensure quality health care for people with disabilities include provision of accommodations that enable clients to participate fully in conversations relating to their health care. The nurse should provide a sign language interpreter. Family members should not be asked to act as an interpreter. Communicating only in written format limits communication.

Which action is included in a nurse's role when providing home care for a client with Alzheimer disease? A. Provide emotional and physical support B. Provide assistance with administering IV fluids C. Support patient with household errands D. Provide assistance with administering oxygen

Provide emotional and physical support Home health care nurses provide emotional support and intervene if family caregivers become overburdened. The nurse also instructs the family about physical care, the disease process, and treatment. Administering IV and oxygen or supporting patients with household errands is not a relevant role for a home nurse.

Neurons communicate with each other through which structure? A. Dendrites B. Neural crest cells C. Synapses D. Cell bodies

Synapses Neurons communicate with each other through structures known as synapses. Cell bodies and dendrites are covered in synapses. Neural crest cells migrate aways from the forming neural tube and are progenitors to the parasympathetic nervous system.

A client who is being seen in the outpatient clinic reports a single episode of unilateral arm and leg weakness and blurred vision that lasted approximately 45 minutes. The client is most likely experiencing: A. Thrombotic stroke B. Transient ischemic attack (TIA) C. Lacunar infarct D. Cardiogenic embolic stroke

Transient ischemic attack (TIA) Transient ischemic attacks are brief episodes of neurologic function resulting in focal cerebral ischemia not associated with infarction that usually resolve in 24 hours. The causes of transient ischemic attack are the same as they are for stroke. Embolic stroke usually has a sudden onset with immediate maximum deficit. Lacunar infarcts produce classic recognizable "lacunar syndromes" such as pure motor hemiplegia, pure sensory hemiplegia, and dysarthria with clumsy hand syndrome.

A 45-year-old client is admitted to the facility with excruciating paroxysmal facial pain. He reports that the episodes occur most often after feeling cold drafts and drinking cold beverages. Based on these findings, the nurse determines that the client is most likely suffering from which neurologic disorder? A. Bell's palsy B. Migraine headache C. Angina pectoris D. Trigeminal neuralgia

Trigeminal neuralgia Trigeminal neuralgia, a painful disorder of one or more branches of cranial nerve V (trigeminal), produces paroxysmal attacks of excruciating facial pain. Attacks are precipitated by stimulation of a trigger zone on the face. Triggering events may include light touch to a hypersensitive area, a draft of air, exposure to heat or cold, eating, smiling, talking, or drinking hot or cold beverages. It occurs most commonly in people older than age 40. Bell's palsy is a disease of cranial nerve VII that produces unilateral or bilateral facial weakness or paralysis. Migraine headaches are throbbing vascular headaches that usually begin to occur in childhood or adolescence. Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Occasionally, jaw pain may indicate angina pectoris.

When caring for a client after ear surgery, what is an important aspect of nursing care? A. Assess social support. B. Feed small frequent meals to minimize nausea. C. Fit for a hearing aid. D. Validate client's feelings of discomfort.

Validate client's feelings of discomfort. Validate client's feelings of discomfort. This measure promotes the nurse-client relationship and reassures the client that his or her needs are important.

A pregnant client is excited that she is beginning to feel her baby move within her. The nurse explains that these first fetal movements are known as: A. lordosis. B. amenorrhea. C. lactation. D. quickening.

quickening. The first fetal movements that the pregnant woman feels are called quickening and usually occur between 18 and 20 weeks of gestation. Amenorrhea is the absence of menstruation and is one of the first indications of pregnancy. Lactation is the production of breast milk in preparation for breastfeeding. Lordosis is the inward curve of the lower back, which becomes exaggerated during pregnancy.

A client with spinal cord injury has no awareness of the need to void. This type of incontinence is termed A. stress incontinence. B. functional incontinence. C. toilet incontinence. D. reflex (neurogenic) incontinence.

reflex (neurogenic) incontinence. Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Stress incontinence is associated with weakened perineal muscles that permit leakage of urine when intra-abdominal pressure is increased. Toilet incontinence occurs in clients who cannot control excreta because of physiologic or psychological impairment. Functional incontinence occurs in clients with intact urinary physiology who experience mobility impairment, environmental barriers, or cognitive problems and can not reach and use the toilet before soiling themselves.