Sensory Perception

The nurse is supervising a family member who instilling ear drops into the client's ear. Which of the following statements, made by the family member, would require further nursing instruction? a. "These drops are cold from being on the window sill." b. "Let me put this cotton ball in your ear because I put the drop in." c. "I squeeze the dropper to put a drop of medicine in the ear." d. "Turn your head to the side so I can put these drops in."

a. "These drops are cold from being on the window sill."

Hearing aids help with which of the following problems? a. Improves discrimination of words b. Makes sounds louder c. Improves understanding of speech d. Improves communication skills

b. Makes sounds louder

What is the term for a rhythmic contraction of a muscle? a. hypertrophy b. clonus c. crepitus d. atrophy

b. clonus

Which nerve is implicated in the Chvostek's sign? a. spiral accessory b. facial c. optic d. hypoglossal

b. facial

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. After administration of the medication, there will be no change in the status of the ptosis or facial weakness. b. Eight hours after administration, the acetylcholinesterase begins to regenerate the available acetylcholine and will relieve symptoms. 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.

c. Thirty seconds after administration, the facial weakness and ptosis will be relieved for approximately 5 minutes.

A client is diagnosed with Meniere's disease. The nurse would most likely expect the client to report which of the following? a. nausea b. ear fullness c. vertigo d. tinnitus

c. vertigo

A client complains of vertigo. The nurse anticipates that the client may have a problem with which portion of the ear? a. middle ear b. external ear c. tympanic membrane d. inner ear

d. inner ear

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? a. astigmatism b. emmetropia c. hyperopia d. myopia

d. myopia

The nurse knows that symptoms associated with a TIA, usually a precursor of a future stroke, usually subside in what period of time? a. 3-6 hours b. 1 hour c. 24-36 hours d. 12 hours

b. 1 hour

A client reports to the nurse that her mother had macular degeneration and is concerned that she, too, may be at risk. What should the nurse tell the client? a. Reduce the amount of cigarettes smoked daily from 20 to 10. b. Wear sunglasses with ultraviolet (UV) protection when outside. c. Vision loss is not hereditary. It is related to diet. d. This condition is now curable.

b. Wear sunglasses with ultraviolet (UV) protection when outside.

A client suffered trauma to the sclera and is being treated for a subsequent infection. During client education, the nurse indicates where the sclera is attached. Which structure would not be included? a. cornea b. eyelids c. iris d. pupil

b. eyelids

During a routine eye examination, a patient complains that she is unable to read road signs at a distance when driving her car. What should the patient be assessed for? a. presbyopia b. myopia c. anisometropia d. astigmatism

b. myopia

When undergoing testing of visual acuity with a Snellen chart, the client can read the line labeled 20/50 but misses three letters on the line. The nurse documents this finding as which of the following? a. 20/50 b. 20/20 + 30 c. 20/50-3 d. 20/20/50

c. 20/50-3

The nurse is assessing the pupils of a patient who has had a head injury. What does the nurse recognize as a parasympathetic effect? a. dilated pupil b. one pupil is dilated and the opposite pupil is normal c. constricted pupils d. roth's spots

c. constricted pupils

The anesthesiologist administered a trans-sacral conduction block. Which documentation by the nurse is consistent with the anesthesia being administered? a. no movement in right lower leg b. unresponsive to verbal or tactile stimuli c. denies sensation to perineum and lower abdomen d. yelling and pulling at equipment

c. denies sensation to perineum and lower abdomen

The nurse is assessing a client's hearing using the Rinne test. When providing instruction to elicit client feedback, which instruction is essential? a. Raise your hand when you hear the vibration. b. Raise your hand when the vibration exceeds the sound. c. Raise your hand when the sound exceeds the vibration. d. Raise your hand when you no longer hear sound.

d. Raise your hand when you no longer hear sound.

Which diagnostic test would the nurse expect to be ordered for a client with lower extremity muscle weakness? a. arthrocentesis b. bone scan c. biopsy d. electromyograph (EMG)

d. electromyograph (EMG)

A client with rheumatoid arthritis has infiltration of the lacrimal and salivary glands with lymphocytes as a result of the disease. What does the nurse understand that this clinical manifestation is? a. episcleritis b. cataracts c. glaucoma d. sicca syndrome

d. sicca syndrome

The nurse is performing a Weber test on a client. During this test, where should the nurse place the tuning fork? a. near the external meatus of each ear b. on the mastoid process behind the ear c. under the bridge of the nose d. in the midline of the client's skull or in the center of the forehead

d. in the midline of the client's skull or in the center of the forehead

A client has developed diabetic retinopathy and is seeing the physician regularly to prevent further loss of sight. From where do the nerve cells of the retina extend? a. oculomotor nerve b. trigeminal nerve c. trochlear nerve d. optic nerve

d. optic nerve

During a routine physical examination to assess a client's deep tendon reflexes, a nurse should make sure to: a. hold the reflex hammer tightly b. tap the tendon slowly and softly. c. use the pointed end of the reflex hammer when striking the Achilles tendon. d. support the joint where the tendon is being tested.

d. support the joint where the tendon is being tested.

The sympathetic and parasympathetic nervous systems have a direct effect on the circulatory system. Stimulation of the parasympathetic nervous system (PNS) causes which of the following? a. heartbeat to decrease b. Blood vessels in the skeletal muscles to dilate c. Blood pressure to increase d. Blood vessels in the heart muscle to dilate

a. heartbeat to decrease

A client with chronic kidney disease reports generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures? a. hyperphosphatemia b. elevated serum creatinine c. hyperkalemia d. elevated urea and nitrogen

a. hyperphosphatemia

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? a. lethargy and stupor b. bradycardia c. hypertension d. a bounding pulse

a. lethargy and stupor

A client with a diagnosis of pernicious anemia comes to the clinic reporting of numbness and tingling in his arms and legs. What do these symptoms indicate? a. neurologic involvement b. insufficient intake of dietary nutrients c. severity of the disease d. loss of vibratory and position senses

a. neurologic involvement

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. presbyopia b. cataract c. myopia d. macular degeneration

a. presbyopia

The nurse teaches the client that corticosteroids will be used to treat his brain tumor to a. reduce cerebral edema b. identify the precise location of the tumor c. prevent extension of the tumor d. facilitate regeneration of neurons

a. reduce cerebral edema

A nurse is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication? a. tetany b. thyroid storm c. laryngeal nerve damage d. hemorrhage

a. tetany

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. trigeminal neuralgia b. angina pectoris c. bell's palsy d. migraine headache

a. trigeminal neuralgia

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot? a. Nausea, vomiting, and profuse sweating b. Hemiplegia, seizures, and decreased level of consciousness c. Tachycardia, tachypnea, and hypotension d. Difficulty breathing or swallowing

b. Hemiplegia, seizures, and decreased level of consciousness

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? a. The client is in hypovolemic shock. b. The client has experienced extensive full-thickness burns. c. The client has experienced partial-thickness burns. d. The paramedic administered high doses of opioids during transport.

b. The client has experienced extensive full-thickness burns.

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what? a. cerebral aneurysm b. transient ischemic attack c. left-sided stroke d. right-sided stroke

b. transient ischemic attack

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? a. A head elevation of 90 degrees to prevent cerebral swelling b. Supine, with the head of the bed elevated 30 degrees c. Flat, except for logrolling as needed d. Flat

c. Flat, except for logrolling as needed

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level? a. slow, shallow respirations b. Arm and leg trembling c. Rapid, thready pulse d. Cool, moist skin

c. Rapid, thready pulse

When the patient tells the nurse that his vision is 20/200, and asks what that means, the nurse informs the patient that a person with 20/200 vision: a. Sees an object from 20 feet away that a person with normal vision sees from 20 feet away. b. Sees an object from 200 feet away that a person with normal vision sees from 200 feet away. c. Sees an object from 20 feet away that a person with normal vision sees from 200 feet away. d. Sees an object from 200 feet away that a person with normal vision sees from 20 feet away.

c. Sees an object from 20 feet away that a person with normal vision sees from 200 feet away.

A nurse practitioner examines a patient suspected of having endometriosis. The nurse knows that although a definitive diagnosis could not be made without diagnostic treatment (transvaginal ultrasound), the most frequent symptom is: a. dyspareunia b. dysuria c. chronic pelvic pain d. low back pain

c. chronic pelvic pain

The nurse is triaging victims after an explosion at an oil refinery. One victim reports tinnitus, dizziness, and otorrhea. For what probable condition should the nurse prepare care? a. head injury b. abdominal injury c. tympanic rupture d. blast lung

c. tympanic rupture

The occupational nurse is advising a client on options to enhance workplace communication because the client has progressive hearing loss. The client works as a customer service representative. In discussing the options with the client, which type would be the last option offered by the nurse? a. Text-based telecommunications b. Headsets with amplifiers c. Battery-operated hearing aid d. American sign language

d. American sign language

A client informs the nurse of having abdominal pain that is relieved when having a bowel movement. The health care provider diagnosed the client with irritable bowel syndrome. What does the nurse recognize as characteristic of this disorder? a. Client is awakened from sleep due to abdominal pain. b. Weight loss due to malabsorption c. Blood and mucus in the stool d. Chronic constipation with sporadic bouts of diarrhea

d. Chronic constipation with sporadic bouts of diarrhea

A client is waiting in a triage area to learn the medical status of family members following a motor vehicle accident. The client is pacing, taking deep breaths, and handwringing. Considering the effects in the body systems, what does the nurse anticipate the liver will do? a. produce a toxic byproduct in relation to stress b. Maintain a basal rate of functioning. c. Cease function and shunt blood to the heart and lungs. d. Convert glycogen to glucose for immediate use.

d. Convert glycogen to glucose for immediate use.

Which of the following drugs may be used after a seizure to maintain a seizure-free state? a. Ativan b. Valium c. Cerebyx d. Phenobarbital

d. Phenobarbital

After a seizure, the nurse should place the patient in which of the following positions to prevent complications? a. High Fowler's, to prevent aspiration b. Semi-Fowler's, to promote breathing c. Supine, to rest the muscles of the extremities d. Side-lying, to facilitate drainage of oral secretions

d. Side-lying, to facilitate drainage of oral secretions

A nurse is preparing to perform the whisper test to assess a client's gross auditory acuity. Which of the following would be most appropriate for the nurse to do? a. Have the client use a finger to occlude the ear to be tested. b. Speak a phrase in a low normal tone of voice. c. Stand at a position diagonal to the client. d. Stand about 1 to 2 feet away from the ear to be tested.

d. Stand about 1 to 2 feet away from the ear to be tested.

A client comes to the emergency department complaining of localized pain and swelling of the lower leg. Ecchymotic areas are noted. History reveals that the client got hit in the leg with a baseball bat. Which of the following would the nurse suspect as most likely? a. strain b. sprain c. fracture d. contusion

d. contusion

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 glucose level of 52 mg/dl b. Serum glucose level of 450 mg/dl c. Serum calcium level of 8.9 mg/dl d. Serum calcium level of 10.2 mg/dl

a. Serum glucose level of 52 mg/dl

Which of the following tests uses a tuning fork between two positions to assess hearing? a. Weber b. Whisper c. Watch tick d. Rinne

a. Weber

Which symptoms may a client with Ménière disease report before an attack? a. a fuller feeling in the ear b. photosensitivity c. low blood pressure d. nystagmus

a. a fuller feeling in the ear