Sensory Perception

The client has various sensory impairments associated with type 1 diabetes. The nurse determines that the client needs further instruction when the client says: a) "I will carefully test the temperature of my bathwater." b) "I will avoid kitchen activities." c) "I will inspect my skin daily for pressure points and injury." d) "I will avoid hot water bottles or heating pads."

"I will avoid kitchen activities."

A client with dementia who prefers to stay in his room has been brought to the dayroom. After 10 minutes, the client becomes agitated and retreats to his room again. The nurse decides to assess the conditions in the dayroom. Which is most likely the occurrence that is disturbing to this client? a) A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner. b) A housekeeping staff member is washing off the countertops in the kitchen, which is on the far side of the dayroom. c) There are three staff members and one health care provider (HCP) in the nurse's station working on charting. d) There is only one other client in the dayroom; the rest are in a group session in another room.

A relaxation tape is playing in one corner of the room, and a television airing a special on crime is playing in the opposite corner.

An elderly client has suffered a cerebrovascular accident (CVA). The right side of the client's face has visible ptosis. The nurse would be alert to which of the following? a) Dysphagia b) Epistaxis c) Agenesis d) Xerostomia

Dysphagia

The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child? a) Avoid startling the child by limiting excess noise. b) Request that the parents stay with the child. c) Use visual aids to facilitate communication. d) Maintain a tidy environment around the child.

Maintain a tidy environment around the child.

Which of the following nursing intervention can prevent a client from experiencing autonomic dysreflexia? a) Administering zolpidem tartrate b) Placing the client in the Trendelenburg's position c) Assessing laboratory test results as ordered d) Monitoring the patency of an indwelling urinary catheter

Monitoring the patency of an indwelling urinary catheter

Which instruction should the nurse include in the teaching plan for a client with seizures who is going home with a prescription for gabapentin? a) Take gabapentin with an antacid to protect against ulcers. b) Notify the health care provider (HCP) if vision changes occur. c) Store gabapentin in the refrigerator. d) Take all the medication until it is gone.

Notify the health care provider (HCP) if vision changes occur.

Which goal is a priority for a client who has undergone surgery for retinal detachment? a) Cleanse the eye with soap and water. b) Control pain. c) Maintain a darkened environment. d) Prevent an increase in intraocular pressure.

Prevent an increase in intraocular pressure

Eardrops have been prescribed to be instilled in the adult client's left ear to soften cerumen. To position the client, what should the nurse do? a) Pull the auricle lobe up and back. b) Chill the eardrops prior to administering. c) Have the client lie on the left side. d) Pull the ear lobe down and back.

Pull the auricle lobe up and back.

What assessment findings would indicate an emergency myasthenia crisis? a) Severe dyspnea, intensification of dysphagia, and dysarthria b) Paralysis of the muscles and hyperventilation c) Airway obstruction, profound muscle weakness, and inability to move d) Impairment of functioning of the autonomic and skeletal muscles

Severe dyspnea, intensification of dysphagia, and dysarthria

The nurse is caring for a client who sustained a head injury during a football game. The nurse is completing the following examination. Which documentation by the nurse provides normal results of this examination? a) The client's retina is attached with no signs of tearing. b) The client's pupils are equal and reactive to light and accommodation. c) The client's vision is 20/20 in both eyes. d) The client's visual field is 360 degrees.

The client's pupils are equal and reactive to light and accommodation.

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 respiratory rate. b) a decreased perceptual field. c) heightened concentration. d) a decreased heart rate.

a decreased perceptual field.

Which activity is least effective in preventing sensory deprivation during a client's stay in the cardiac care unit? a) visiting with family b) keeping the door closed to provide privacy c) watching television d) reading the newspaper

keeping the door closed to provide privacy

When obtaining the health history from a client with retinal detachment, a nurse expects the client to report: a) a recent driving accident while changing lanes. b) headaches, nausea, and redness of the eyes. c) frequent episodes of double vision. d) light flashes and floaters in front of the eye.

light flashes and floaters in front of the eye.

While shopping at a mall, a woman experiences an episode of extreme terror accompanied by anxiety, tachycardia, trembling, and fear of going crazy. A friend drives her to the emergency department, where a physician rules out physiologic causes and refers her to the psychiatric resident on call. To control the client's anxiety, the nurse caring for this client expects the resident to order: a) paroxetine. b) haloperidol. c) lorazepam. d) bupropion.

lorazepam.

For the client who has difficulty falling asleep at night because of withdrawal symptoms from alcohol, which are abating, which nursing intervention is likely to be most effective? a) advising the client to take multiple short naps during the day until symptoms improve b) allowing the client to sit in the community room until the client feels sleepy c) teaching the client relaxation exercises to use before bedtime d) inviting the client to play a board game with the nurse

teaching the client relaxation exercises to use before bedtime