Med/Surg: PrepU Sensory Perception

A client with a recent left above-the-knee amputation states, "I can feel pain in my left toes." Which is the best response by the nurse?

"Describe the pain and rate it on the pain scale."

Which symptoms may a client with Ménière disease report before an attack?

A full feeling in the ear

You are teaching a class on diseases of the ear. What would you teach the class is the most characteristic symptom of otosclerosis?

A progressive, bilateral loss of hearing

On ocular examination, the health care provider notes severely elevated IOP, corneal edema, and a pupil that is fixed in a semi-dilated position. The nurse knows that these clinical signs are diagnostic of the type of glaucoma known as:

Acute angle-closure.

A client who recently experienced a stroke tells the nurse that he has double vision. Which nursing intervention is most appropriate?

Alternatively patch one eye every 2 hours.

A client arrives at the orthopedic physician's office stating knee pain sustained while playing soccer. A history and physical assessment is completed. The knee appears reddened with edema. Which other diagnostic testing would the nurse anticipate?

An arthroscopy

A client presents with peripheral neuropathy and hypoesthesia of the feet. What is the best nursing intervention?

Assess for signs of injury.

Which assessment should be completed if immune dysfunction is suspected in the neurosensory system?

Ataxia

A patient is to have an angiography done using fluorescein as a contrast agent to determine if the patient has macular edema. What laboratory work should the nurse monitor prior to the angiography?

BUN and creatinine

A client you are caring for has a hearing loss. The client tells you he is self-conscious about his hearing loss. What advice should the nurse give a self-conscious client with hearing loss to protect his self-esteem?

Be forthright and inform others about the hearing deficit.

The nurse obtains a Snellen eye chart when assessing cranial nerve function. Which cranial nerve is the nurse testing when using the chart?

CN II

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:

Chronic pelvic pain.

The nurse is caring for a client experiencing hearing loss. The nurse uses the otoscope to assess the ear canal and tympanic membrane and notes a significant accumulation of cerumen. Which documentation of hearing loss type would be most accurate?

Conductive

Which of the following is the main refracting surface of the eye?

Cornea

The nurse is assessing a 78-year-old woman and suspects that the patient may have age-related macular degeneration. Which assessment finding would most likely support this suspicion?

Diminished color perception

The nurse is preparing a patient for a gynecologic examination when the patient says, "I hope the exam doesn't hurt as much as intercourse with my husband does." What should the nurse document this finding as?

Dyspareunia

Which of the following diagnostics are used to evaluate spinal nerve root disorders (radiculopathies)?

Electromyogram

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

Eye opening Verbal response Motor response

The family of an older adult seeks medical attention for the client because of an increase in inappropriate responses and avoidance of social interactions. On which body area will the nurse focus when assessing the client?

Hearing

The nurse is caring for a client in the triage section of a walk-in clinic. Which triad of common symptoms suggests a diagnosis of Ménière disease?

Hearing loss, vertigo, tinnitus

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?

Hyperphosphatemia

The client is having a Weber test. During a Weber test, where should the tuning fork be placed?

In the midline of the client's skull or in the center of the forehead

A client comes to the walk-in clinic reporting feeling a "bug in my ear." What action should be taken when there is an insect in the ear?

Instillation of mineral oil

An ophthalmologist tells a patient that he has a cataract. The nurse explains to the patient that this means there is:

Interference with focusing of a sharp image.

What clinical manifestations does the nurse recognize when a patient has had a right hemispheric stroke?

Left visual field deficit

A nurse conducted a history and physical for a newly admitted patient who states, "My arms are too short. I have to hold my book at a distance to read." The nurse knows that the patient is most likely experiencing:

Loss of accommodative power in the lens.

Which of the following describes vertigo? Select all that apply.

Misperception of motion, Spinning sensation, Objects are moving around him or her

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate

The nurse is performing an initial nursing assessment on a client with possible Guillain-Barre syndrome. Which of the following findings would be most consistent with this diagnosis?

Muscle weakness and hyporeflexia of the lower extremities

A nurse is admitting a client to the unit who presented with a lower extremity fracture. What signs and symptoms would suggest to the nurse that the client may have a peroneal nerve injury?

Numbness and burning of the foot

The nurse is assessing an older adult patient just admitted to the hospital. Why is it important that the nurse carefully assess pain in the older adult patient?

Older people experience reduced sensory perception.

Following morning hygiene of an older adult client, the nurse is unable to replace the retracted foreskin of the penis. Which is the most likely outcome?

Painful swelling

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?

Parasympathetic

The nurse observes a client with a shuffling gait. What disease is commonly associated with a shuffling gait?

Parkinson's disease

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Phenobarbital

Which terms refers to the progressive hearing loss associated with aging?

Presbycusis

A client with acromegaly is admitted to the hospital with complaints of partial blindness that began suddenly. What does the nurse suspect is occurring with this client?

Pressure on the optic nerve

The nurse is caring for a client who communicates via sign language. What should the nurse do to promote communication?

Provide a sign language interpreter.

The nurse practitioner is able to correlate a patient's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a patient with a left hemispheric stroke, the nurse would expect to see:

Right-sided paralysis.

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:

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

During his annual physical examination, a retired airplane mechanic reports noticeable hearing loss. The nurse practitioner prescribes a series of hearing tests to confirm or rule out noise-induced hearing loss, which is classified as a:

Sensorineural loss.

After a seizure, the nurse should place the patient in which of the following positions to prevent complications?

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?

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

A patient with Bell's palsy says to the nurse, "It doesn't hurt anymore to touch my face. How am I going to get muscle tone back so I don't look like this anymore?" What interventions can the nurse suggest to the patient?

Suggest massaging the face several times daily, using a gentle upward motion, to maintain muscle tone.

The nurse is caring for a client who has presented to the walk-in clinic. The client verbalizes pain on urination, feelings of fatigue, and diffuse back pain. When completing a head-to-toe assessment, at which specific location would the nurse assess the client's kidneys for tenderness?

The costovertebral angle

Which statement describes benign paroxysmal positional vertigo (BPPV)?

The vertigo is usually accompanied by nausea and vomiting.

Which statement describes benign paroxysmal positional vertigo (BPPV)?

The vertigo is usually accompanied by nausea and vomiting; generally, however, hearing is not impaired.

A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect?

Urinary calculi

A patient comes to the emergency department with severe pain in the face that was stimulated by brushing the teeth. What cranial nerve does the nurse understand can cause this type of pain?

V

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines?

Verapamil (Calan)

A client has a history of hearing loss and is returning for an annual hearing examination. During client education, the nurse explains that hearing involves which areas of the ear?

all sections

During assessment for cranial nerve functions, the client closes the eyes and begins to fall to one side. Which cranial nerve alteration causes this response?

cranial nerve VIII

A client with multiple sclerosis is being seen by a neuro-ophthalmologist for a routine eye exam. The nurse explains to the client that during the examination, the client will be asked to maintain a fixed gaze on a stationary point while an object is moved from a point on the side, where it can't be seen, toward the center. The client will indicate when the object becomes visible The nurse further explains that the test being performed is called a:

perimetry test

A patient is treated for a neurologic dysfunction affecting facial expressions. The affected cranial nerve originates in the:

pons.

A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of:

profound neuromuscular irritability.

A client is having a routine eye examination. The procedure being performed is done by using an instrument to indent or flatten the surface of the eye. This is known as ________ and it is routinely done to test for ________.

tonometry; intraocular pressure