Sensory / Perception EAQ
After cataract surgery, a client reports feeling nauseated. How can the nurse help to relieve the nausea? Correct1 Administer the prescribed antiemetic drug. 2 Provide some dry crackers for the client to eat. 3 Explain that this is expected following surgery. 4 Teach how to breathe deeply until the nausea subsides.
Correct1 Administer the prescribed antiemetic drug. An antiemetic will prevent vomiting; vomiting increases intraocular pressure and should be avoided. The other options are unsafe; vomiting increases intraocular pressure, and aggressive intervention is required.
A client asks for information about glaucoma. The nurse explains that glaucoma is: Correct1 An increase in the pressure within the eyeball 2 An opacity of the crystalline lens or its capsule 3 A curvature of the cornea that becomes unequal 4 A separation of the neural retina from the pigmented retina
Correct1 An increase in the pressure within the eyeball An increase in intraocular pressure (IOP) results from a resistance of aqueous humor outflow. Open-angle glaucoma, the most common type of glaucoma, results from increased resistance to aqueous humor outflow through the trabecular meshwork, Schlemm's canal, and the episcleral venous system. An opacity of the crystalline lens or its capsule is the description of a cataract. A curvature of the cornea that becomes unequal is the description of astigmatism. A separation of the neural retina from the pigmented retina is the description of a detached retina.
A nurse is caring for a newly admitted client in a long-term care facility. The nurse notes that the client has a decreased attention span and cannot concentrate. The nurse suspects which effects of sensory deprivation? Correct1 Cognitive response 2 Emotional response 3 Perceptual response 4 Physical response
Correct1 Cognitive response Clients experiencing a cognitive response exhibit an inability to control the direction of thought content, attention span, and concentration. Clients also experience difficulty with memory, problem solving, and task performance. Clients exhibiting an emotional response exhibit inappropriate emotional responses, such as apathy, anxiety, fear, anger, belligerence, panic, and/or depression. Clients may also experience rapid mood changes. Perceptual response is the inaccurate perception of sights, sounds, tastes, smells, body position, coordination, and equilibrium. Decreased attention span and concentration does not fall within the physical response; they fall within the cognitive response. Test-Taking Tip: Monitor questions that you answer with an educated guess or changed your answer from the first option you selected. This will help you to analyze your ability to think critically. Usually your first answer is correct and should not be changed without reason.
A client who just has been diagnosed with primary open-angle glaucoma (POAG) refuses therapy. The nurse reinforces that it is important for the client to seek treatment because if POAG is left untreated it may lead to: 1 Cataracts Correct2 Blindness 3 Retinal detachment 4 Blurred distance vision
Correct2 Blindness POAG progresses gradually without symptoms. Peripheral vision slowly disappears until tunnel vision occurs in which there is only a small center field. Without treatment, eventually all vision is lost. POAG is not related to the development of cataracts. POAG is not related to the development of retinal detachment. POAG is not related to the development of blurred distance vision.
The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections? 1 Immunological differences between adults and young children Correct2 Structural differences between eustachian tubes of younger and older children 3 Functional differences between eustachian tubes of younger and older children 4 Circumference differences between middle ear cavity size of adults and young children
Correct2 Structural differences between eustachian tubes of younger and older children The eustachian tube in young children is shorter and wider, allowing a reflux of nasopharyngeal secretions. Immunological differences are not a factor in the development of otitis media. There is no difference in the function of the eustachian tube among age groups. The size of the middle ear does not play a role in the occurrence of otitis media in young children.
A nurse is caring for an infant who has undergone myringotomy because of recurrent otitis media. What does the nurse expect to note when providing care to this child? 1 Excessive tearing 2 Difficulty voiding Correct3 Drainage into the external auditory canal 4 Symptoms of central nervous system irritation
Correct3 Drainage into the external auditory canal Myringotomy is an incision made in the tympanic membrane of the ear that relieves pressure and prevents spontaneous rupture of the eardrum by allowing fluid to escape from the middle ear into the external auditory canal. Tearing is not expected, dysurea, and central nervous system irritation are not expected after myringotomy.
When assessing a client, the nurse identifies that the client has weakness of some of the muscles of the body. What should the nurse document in the medical record when describing weakness in the area indicated in the shaded portion of the illustration? 1 Hemiopia 2 Paraplegia Correct3 Hemiparesis 4 Quadriplegia
Correct3 Hemiparesis Hemi is a prefix meaning half; paresis is a combining form meaning incomplete or partial paralysis. Therefore, hemiparesis means muscular weakness of one half of the body as indicated in the illustration. Hemiopia refers to a condition involving only one eye or half the visual field. Paraplegia is paralysis of the lower limbs and trunk of the body. Quadriplegia is paralysis of the arms, legs, and trunk of the body.
The mother of a 2-year-old child tells the nurse that she is concerned about her child's vision. What behavior when the child is tired leads the nurse to suspect strabismus? 1 One eyelid droops. 2 Both eyes look cloudy. Correct3 One eye moves inward. 4 Both eyes blink excessively
Correct3 One eye moves inward. An inward moving eye (tropia) is one form of strabismus. A drooping eyelid is called ptosis; it may be congenital or caused by trauma. Cloudy eyes are associated with congenital cataracts. Blinking may be a tic.
What should a nurse do to decrease or control the sensory and cognitive disturbances that can occur after a client has open-heart surgery? 1 Restrict family visits 2 Withhold analgesic medications Correct3 Plan for maximum periods of rest 4 Keep the room light on most of the time
Correct3 Plan for maximum periods of rest Sleep deprivation alone can cause these disturbances because of the interruption in rapid eye movement (REM) sleep. Lack of contact with significant others increases anxiety and feelings of isolation, which can lead to disturbances in rest. Pain limits or interrupts periods of sleep and rest. Analgesics should be administered as prescribed. Constant light increases cerebral arousal and limits sleep. Test-Taking Tip: Study wisely, not hard. Use study strategies to save time and be able to get a good night's sleep the night before your exam. Cramming is not smart, and it is hard work that increases stress while reducing learning. When you cram, your mind is more likely to go blank during a test. When you cram, the information is in your short-term memory so you will need to relearn it before a comprehensive exam. Relearning takes more time. The stress caused by cramming may interfere with your sleep. Your brain needs sleep to function at its best.
When teaching about aging, the nurse explains that older adults usually have: 1 Inflexible attitudes 2 Periods of confusion Correct3 Slower reaction times 4 Some senile dementia
Correct3 Slower reaction times A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. The majority of older adults do not have organic mental disease.
A nurse is teaching the parents of an 18-month-old child the procedure for instilling ear drops. How should this procedure be done? 1 By cleansing the ear canal before instilling the drops 2 By applying medicated ear wicks after instilling the drops 3 By pulling the pinna up and back after drop instillation to promote dispersement of the drops Correct4 By pulling the pinna down and back to straighten the auditory canal before instillation of the drops
Correct4 By pulling the pinna down and back to straighten the auditory canal before instillation of the drops The canal curves upward in children younger than 3 years of age; pulling the pinna down straightens the canal so medication will reach the eardrum. The ear canal is not cleansed before ear drops are instilled; this could exacerbate the infection. Applying ear wicks is contraindicated because it increases pressure within the ear. Pulling the pinna up and back after instillation of drops is unnecessary; pressing on the tragus several times will help disburse the drops.
A client with a detached retina is scheduled for surgery to reattach the retina. What should the nurse address in the preoperative teaching plan about the procedure used with this surgery? 1 Radiation 2 Burr holes 3 Dermabrasion Correct4 Laser technique
Correct4 Laser technique A laser beam causes a thermal inflammatory response, which results in a chorioretinal scar that holds the retina in place. Radiation is not used because it destroys retinal tissue. Burr holes are used in brain, not retinal, surgery. Dermabrasion is used for acne vulgaris and other disfiguring skin conditions, not retinal surgery.
The nurse recognizes that the mental process most sensitive to deterioration with aging is: 1 Judgment 2 Intelligence 3 Creative thinking Correct4 Short-term memory
Correct4 Short-term memory During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease in its blood supply, which may produce a tendency to become forgetful, a reduction in short-term memory, and susceptibility to personality changes. There should be little or no change in judgment. There is little or no intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many people remain creative until very late in life.
During a well-child visit the parents tell a nurse, "Our 3-year-old doesn't listen to us when we speak—he ignores us!" An auditory screening reveals that the child has a mild hearing loss. What should the nurse explain to the parents about this degree of hearing loss? 1 A severe hearing deficit may develop. 2 It will not interfere with progress in school. 3 An immediate follow-up visit is not necessary. Correct4 Speech therapy in addition to hearing aids may be required.
Correct4 Speech therapy in addition to hearing aids may be required. A mild degree of hearing loss causes the child to miss approximately 25% to 40% of conversations; it may result in speech deficits and interfere with the child's educational progress if it is not corrected. Hearing aids usually help improve function. There is no evidence that this child's hearing loss is progressive. The significance of the hearing loss requires further analysis and intervention. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know.