ATI Sensory
A nurse is caring for a client who has hearing impairment. Which of the following actions should the nurse take when communicating with the client? A. face the client when speaking B. speak in a loud voice C. use a normal rate when speaking D. avoid hand motions
A. face the client when speaking Facing the client allow the client to observe the nurse's facial expressions and to lip read during the communication process.
A nurse is caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote the client's safety? A. Initiate seizure precaution B. Ensure the client receives a soft diet C. Provide an obstacle-free path for ambulation D. Instruct the client to use lukewarm water when showering
C. Provide an obstacle-free path for ambulation Although providing an obstacle-free path is a safety precaution for all clients, it is especially crucial for this client. Cranial nerve III is the optic nerve; therefore, the client has at least some visual challenges and will need an obstacle-free path for ambulation.
A nurse is assessing a client who has a new diagnosis of acute angle-closure glaucoma. The nurse should anticipate the client to report which of the following manifestations? A. multiple floaters B. flashes of light in front of the eye C. severe eye pain D. double vision
C. severe eye pain Severe eye pain is a manifestation of acute angle-closure glaucoma. Other manifestations can include report of halos around lights, blurred vision, HA, brow pain, and N/V
A nurse is teaching a client who has a new diagnosis of primary open-angle glaucoma (POAG). Which of the following pieces of information should the nurse include in the teaching? SATA A. lost of vision can improve with eyed drops B. administer eye drops as needed for vision loss C. glasses will be necessary for vision loss D. driving can be dangerous due to the loss of peripheral vision E. laser surgery can help reestablish the flow of aqueous humor.
D, E. Damage to the optic nerve that occurs secondary to increased intraocular pressure causes a decrease in peripheral vision and can lead to complete vision loss if not treated. Laser surgery can reopen the trabecular meshwork and widen the canal of Schlemm.
A nurse is providing discharge teaching to a client who is postoperative following cataract surgery and has an intraocular lens implant. Which of the following statements by the client indicates an understanding of the instructions? A. "I will sleep on the affected side." B. "I will avoid bending over." C. "I will restrict caffeine in my diet" D. "I will take aspirin to relieve my pain"
B. "I will avoid bending over." The nurse should instruct client to avoid activities that can increase intraocular pressure, such as lifting, bending, coughing, or performing the Valsalva maneuver. An increase in intraocular pressure can create intraocular hemorrhage.
A nurse is assessing a client who reports vision loss. The client describes the loss as beginning with a "flash" of light followed by a "curtain" across the field of vision. The nurse should identify that these manifestations indicate which of the following? A. Glaucoma B. Retinal detachment C. Macular degeneration D. Cataracts
B. Retinal detachment A flash of light and a sudden loss of vision are manifestations of retinal detachment. Client reports the event of vision loss as sudden and painless Glaucoma - sudden, severe pain around the eyes. The pain radiates over the face, and the client reports a HA, halos around lights, and a sudden blurred vision. Macular Degeneration - decline of central vision leading to a total loss. Clients often report mild blurring and distortion. Cataracts - blurred vision and decreased color perception at first, followed by a lens of cloudiness that continues gradually until a loss of vision occurs in all visual fields.
A nurse is assessing a client who has cataracts. Which of the following should the nurse expect? A. pupils nonreactive to light B. opacity visible behind the pupil C. white circle around the outside border of the iris D. increased intraocular pressure
B. opacity visible behind the pupil With a cataract, the lens of the eye becomes thick and opaque with age and appears as opacity behind the pupil when the nurse shines a light on the area.
