Neurosensory Test 3
A 90-year-old nursing home resident with Alzheimer's disease is found alone and crying in the dining room. She says she lost her mother and doesn't know what to do. Which response by the nurse will help calm the resident?
"Are you feeling scared? I'm here and I will help you."
The nurse is assisting in the evaluation of the effectiveness of teaching for a patient who has a severe visual impairment. Which statement by the patient indicates additional teaching is needed?
"Cooking is still impossible and I am just eating cold foods."
The nurse is reinforcing teaching provided to a patient with primary open-angle glaucoma (POAG) about symptoms to report. Which patient statement regarding symptoms indicates a correct understanding of the teaching?
"Headaches and seeing halos around lights."
The nurse is reinforcing teaching provided to a patient recovering from a stapedectomy. Which patient statement indicates teaching has been effective?
"I will cough or sneeze with my mouth open."
A nurse is teaching the partner of a client with Alzheimer's disease and has a new prescription for Donepezil. Which of the following statements by the partner indicates that the instruction is effective?
"This medication should help my husband's daily function."
The caregiver of a patient with macular degeneration voices being increasingly frustrated because of food spills on the patient's clothing. Which explanation does the nurse give to help the caregiver understand what the patient is experiencing?
'The central vision is gone and only peripheral vision remains."
The nurse places eyedrops for a patient with an injured eye and covers the eye with a patch as prescribed. Discharge instructions are given to the patient. Which patient statements indicate further instruction is needed? (Select all that apply)
-I should exercise my patched eye four times daily -I can watch TV without moving my eye too much -I should apply pressure to the tear duct of the eye every 5 minutes -I should try to open my eyelid under the patch hourly while awake
Prior to measuring a patient's hearing, the nurse obtains a tuning fork. Which hearing test is the nurse preparing to conduct? (Select all that apply)
-Rinne test -Weber test
A patient with acute ear pain and drainage comes into the community clinic. Which diagnostic tests does the nurse expect to be performed prior to beginning treatment for this patient? (Select all that apply)
-complete blood count -Rinne and Weber tests -culture of ear discharge
During a health history, the nurse suspects that the patient is at risk for a vision problem. Which information within the family history does the nurse use to make this decision? (Select all that apply)
-diabetes -cataracts -blindness -glaucoma
A patient with otitis media is experiencing severe ear pain. Which nonpharmacologic measures should the nurse use to help this patient? (Select all that apply.)
-offer a massage -apply heat to the area -offer liquid or soft diet
The nurse determines that a patient is experiencing common age-related changes in vision and hearing. Which findings does the nurse identify in the patient? (Select all that apply)
-presbycusis -yellowing of the lens -distorted depth perception -decreased lacrimal secretions
A nurse is caring for a 70-year-old client with Alzheimer's disease. Which of the following risk factors should be included when discussing this disease with family members? (Select all that apply)
-previous head injury -history of exposure to toxins -exposure to waste products like metal
A patient with MS has been prescribed baclofen to relax muscles. Which information is included in the nurses teaching about this drug? (Select all that apply)
-report any shortness of breath or other respiratory problems -avoid driving or operating any heavy machinery until the effects of the drug are known -prevent constipation by increasing fluids and fiber-rich foods, use suppositories when necessary
The nurse is involved in a blood pressure clinic in the community, and an individual with possible stroke symptoms is brought in for evaluation. Which findings in the FAST (Face, Arms, Speech, and Time) assessment indicate the need to call emergency personnel? (Select all that apply)
-the patient is unable to repeat a stated phrase exactly as it was stated -the patient's face shows signs of uneven symmetry when asked to smile -when asked to close the eyes and hold arms straight in front, one arm drifts downward
The nurse is providing care for a patient with expressive aphasia. What would the nurse expect to find in the patient's plan of care? (Select all that apply)
-use a picture board -provide pencil and paper
A HCP prescribes potassium chloride (KCI) elixir, 20 mEq orally daily. The medication label states potassium chloride (KCI) 30 mEq/15 mL. How many milliliters should the nurse prepare to administer the dose?
10 mL
A patient began experiencing manifestations of a stroke at 0800 hours. By which time should thrombolytic medications be provided to reverse stroke symptoms?
1230 hours
After surgery for a detached retina, a patient is experiencing nausea and is prescribed prochlorperazine (Compazine), 10 mg IM prn every 6 hours. Compazine is available as 5mg/mL. How many mL should the nurse administer per dose?
2
The nurse is assisting with a patient who is having a test to measure intraocular pressure. Which equipment should the nurse expect to be used?
A tonometer
The nurse is assisting with the care of patients diagnosed with neuromuscular disorders. Which complication does the nurse recognize as a medical emergency?
Indications of the development of pneumonia
A patient presents with vertigo, tinnitus, and sensorineural hearing loss and is diagnosed with labyrinthitis. Which patient teaching does the nurse reinforce with this patient?
Instruct to not turn the head quickly
A patient comes into the emergency department with unilateral paralysis, aphasia, and inability to follow directions. Which emergency management by the health care provider is unexpected by the nurse?
Maintenance of oxygen therapy to a saturation of at least 94%
The nurse is collecting information about a patient's auditory system during a physical examination. Which process will the nurse perform first?
Observation
The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?
Pupils equal, round, and reactive to light and accommodation
A patient is scheduled to have cataract surgery. Which stricture of the patients eye does the nurse explain will be involved in the procedure?
The lens
A patient is diagnosed with otosclerosis and is scheduled for a stapedectomy. Which postoperative finding does the nurse report to the HCP or the RN immediately?
The patient received an antiemetic for nausea, but vomits after the medication
A patient arrives in the emergency department at 0300 exhibiting the manifestations of a stroke. The patient reports going to bed at 2100 and being negative for symptoms. If the CT reveals an ischemic stroke related to aa blood clot, for which reason is tPA therapy withheld?
The therapy is based on what time the patient went to bed
A patient is diagnosed with Meniere's disease. Which therapeutic measures does the nurse expect the HCP to prescribe?
a salt restricted diet and prescribed antihistamines and vasodilators
The nurse is reviewing the medical records of patients in an HCP's practice. Which patient does the nurse recognize as the greatest risk for a stroke?
an older female who has osteoporosis, a femur fracture and hyperlipidemia
The nurse is preparing to assist a patient with eating who is recovering from a stroke. Which intervention is appropriate?
check the patient's mouth periodically for presence of pocketed food
The nurse is reinforcing teaching provided to a patient with open-angle glaucoma. What is most important for the nurse to include in the patient teaching?
compliance with drug therapy is essential to prevent loss of vision
While checking a patient's pupils, the nurse notes that the left pupil constricts when a light is shone into the right eye. Which information does this finding suggest to the nurse?
consensual response
The nurse is aware that children can be at risk for an embolic stroke. Which condition is least likely to cause a child to have a stroke?
contact sports trauma
The nurse is working at a summer camp for pre-adolescent children. One of the children comes to the nurse rubbing an eye and stating pain from getting sand in the eye. After the child is effectively treated, which teaching is the nurse prompted to provide to all the attendees?
do not rub your eye if it has something in it
The nurse in a HCP's office is assisting with the removal of impacted cerumen from the ear canal of an older patient. The patient presented with decreased hearing and a sensation of fullness. Which reason does the nurse identify as the most likely cause of the patient's condition?
dryness of secretions from shrinking ear canal glands
The nurse is assisting with the care of a patient following an ischemic stroke who does not qualify for tPA therapy. The patients current blood pressure is 190/110 mm Hg. For which reason will the patient's hypertension remain untreated?
permissive hypertension is being therapeutically used to salvage brain tissue
A nurse working in a long-term care facility is caring for a client with Alzheimer's disease and suffered falls previously. Which of the following actions should the nurse take to prevent this from happening again?
place the client in a room near the nurses station
The nurse is preparing to administer eye medication as prescribed by the HCP after eye surgery for cataract removal. The HCP prescribes one drop with punctal occlusion. Which action will the nurse perform when administering this medication?
place the index finger on the corner of the eye and apply pressure against the nose
The nurse is assisting with the preparation of a patient for a cochlear implant due to profound deafness. Which teaching will the nurse reinforce for this patient?
preparation instructions for surgery
A nurse is collecting information from a patient who reports difficulty seeing the print in the newspaper. The patient is 50 years of age and does not have any condition that requires medical management. Which vision condition does the nurse suspect the patient is experiencing?
presbyopia
The nurse is conducting hearing tests in a neighborhood clinic. The nurse is concerned about the number of young adult patients who exhibit signs of sensorineural hearing loss. For which reason does the nurse suspect this type of hearing loss in this population?
prolonged exposure to loud noise
A nurse is providing care for a patient diagnosed with a stroke resulting in language disorder. Which type of disorder does the nurse recognize if the patient raises an arm in response to the nurse's direction to stick out his tongue?
receptive aphasia
The nurse is providing care for an older adult client. The nurse notices the patient appears to be having difficulty understanding her and asks that questions and comments be repeated. If the nurse suspects presbycusis, which action does the nurse take to promote better hearing for the patient?
speak to the patient in a lower tone of voice
The HCP is preparing to discharge a patient from the hospital after a stroke. The patient is insistent on being sent to a rehabilitation center. The nurse is aware that the patient must meet which qualification to go to rehabilitation?
the ability to participate in intensive therapy
The nurse is conducting hearing acuity evaluation on a patient using the Rinne test. The test involves the use of a tuning fork. Which test result will be validated with the documentation AC greater than BC?
the patient continues to hear the tuning fork for twice as long when it is lifted from the mastoid bone
The nurse is giving instructions to a patient who is scheduled for an electronystagmogram due to a diagnosis of vertigo and ringing in the ears. Which finding regarding the patient's medical history will cause the nurse to notify the prescribing HCP for cancellation of the test?
the patient has a pacemaker
The nurse is visiting the home of a patient diagnosed with visual impairment related to macular degeneration. Which observation indicates to the nurse the patient is adjusting to the condition?
the patient is moving about in the apartment with no complications
A patient comes into the emergency room with symptoms of a stroke. Which medication does the nurse expect to be given to the patient if diagnostic testing confirms an ischemic stroke?
tissue-type plasminogen activator (tPA)
The nurse is attending while the HCP performs an otoscopic examination of a patient's ears. The nurse is aware that the examination is performed primarily for which purpose?
to examine the eardrum