b. minimize background noise c. write down what the client does not understand d. allow plenty of time for client to respond e. use brief sentences with simple words Client with recent cerebrovascular accident has aphasia. Which of following should nurse use to promote communication with client? Select all that apply. a. speak fast and loudly b. minimize background noise c. write down what the client does not understand d. allow plenty of time for client to respond e. use brief sentences with simple words c. provide a private room, and limit stimulation Client had recent amphetamine overdose and sensory overload. Which of following interventions should nurse implement? a. immediately complete thorough assessment b. put client in room with client who is hearing impaired c. provide a private room, and limit stimulation d. talk loudly to client, and encourage ambulation a. Weber test showing lateralization to right ear c. No signs of obstruction in the left ear canal d. Rinne test showing length of time is decreased for air and bone conduction Client reports difficulty hearing. Which of following assessment findings indicate sensorineural hearing loss in left ear? Select all that apply. a. Weber test showing lateralization to right ear b. Light reflex at 10 o'clock in the left ear c. No signs of obstruction in the left ear canal d. Rinne test showing length of time is decreased for air and bone conduction e. Rinne test showing air conduction less than bone conduction in the left ear d. I take the batteries out of my hearing aids when I take them off at night. Client is hearing impaired and just started wearing hearing aids. Which of following statements by client indicates understanding of instructions the nurse just reviewed? a. I use a damp cloth to clean outside part of my hearing aids. b. I clean ear molds of hearing aids w/rubbing alcohol. c. I keep volume of hearing aids turned up so I can hear better. d. I take the batteries out of my hearing aids when I take them off at night. a. furosemide (Lasix) b. ibuprofen (Advil) Client has several risk factors for hearing loss. Nurse reviews medication history. Which of following meds the client takes should alert nurse to further risk for ototoxicity? Select all that apply. a. furosemide (Lasix) b. ibuprofen (Advil) c. cimetidine (Tagament) d. simvastatin (Zocor) e. amiodarone (Cordarone) a. Romberg test b. Heel-to-toe walk A nurse is performing neurosensory examination for client. Which of following tests should nurse perform to test balance? Select all that apply. a. Romberg test b. Heel-to-toe walk c. Snellen test d. Spinal accessory function e. Rosenbaum test An older adult client has diabetes mellitus and reports loss of peripheral vision. For which of the following is the client at risk? a. cataracts b. open-angle glaucoma c. macular degeneration d. angle-closure glaucoma
d. You need to limit your housekeeping activities. When caring for a client following trabeculectomy, which of following statements should nurse include in teaching? a. You may resume playing golf. b. You need to tilt your head back when washing your hair. c. You may continue driving to and from work. d. You need to limit your housekeeping activities. b. genetic predisposition c. hypertension d. age e. diabetes mellitus Which of the following should the nurse recognize as risk factors associated with glaucoma? Select all that apply. a. gender b. genetic predisposition c. hypertension d. age e. diabetes mellitus c. blurred vision d. white pupils Which of following clinical manifestations should the nurse expect to find while caring for a client who has a new diagnosis of cataracts? Select all that apply. a. eye pain b. floating spots c. blurred vision d. white pupils e. bilateral red reflexes Which of following actions should the nurse take while assessing a client who is reporting nausea and severe eye pain following cataract surgery? a. notify the provider b. administer an analgesic c. administer an antiemetic d. turn the client onto the operative side d. black cerumen partially occluding tympanic membrane Which of following is an unexpected finding while performing an otoscopic examination of a client? a. pearly, gray tympanic membrane b. malleus visible behind tympanic membrane c. flaky skin in the external ear canal near tympanic membrane d. black cerumen partially occluding tympanic membrane a. reduce exposure to bright lighting b. move head slowly when changing positions d. plan evenly spaced daily fluid intake Which of following should nurse recommend to help control mild to moderate vertigo due to benign paroxysmal vertigo for several weeks? Select all that apply. a. reduce exposure to bright lighting b. move head slowly when changing positions c. avoid fruits high in potassium d. plan evenly spaced daily fluid intake e. avoid smoking d. unilateral hearing loss When caring for a client with suspected Meniere's disease, which of following is expected finding? a. presence of purulent lesion in external ear canal b. recent history of plane travel c. bulging, red bilateral tympanic membranes d. unilateral hearing loss a. enlarged adenoids b. report of recent colds e. report of frequent ingestion of ibuprofen While reviewing the health record of a client who has middle ear disorder, which of following are expected findings? Select all that apply. a. enlarged adenoids b. report of recent colds c. dc'd furosemide prescription 6 months ago d. light reflexes visible on otoscopic exam at 5 & 7 o'clock e. report of frequent ingestion of ibuprofen b. I will cover my ear when washing my hair. Which of the following statements by the client indicates understanding of discharge teaching following stapedectomy? a. I am glad I'll be able to return to my position as an airplane pilot right away. b. I will cover my ear when washing my hair. c. I will remove the dressing behind my ear in 7 days d. I can expect my hearing to return in 24 hours. Mrs Pfannestiel was most likely having difficulty doing __________ if she was scheduled for cataract surgery?
b. Selecting clothes that match c. Reading a book since letters appeared small d. Reading a book because she had double vision Your client has double vision, which is also known as a. Presbyopia b. Emmetropia c. Diplopia d. Ametropia Your 80 year old client has had a progressive hearing loss over the past 8 months, has refused to participate in activities at the skilled nursing home, and has often been found alone in his room. Which nursing diagnosis is most appropriate? a. Social isolation b. Altered thought processes c. Disturbed sensory perception: auditory d. Self care deficit b. The eye can see at 20 feet what the normal eye can see at 80 feet. Which of the following would the nurse explain to the patient is indicated by a Snellen chart finding of 20/80? a. The eye can see at 80 feet what the normal eye can see at 20 feet b. The eye can see at 20 feet what the normal eye can see at 80 feet c. The eye can see four times what the normal eye can d. The eye sees normally d. Light is reflected at the same spot in both eyes Which would indicate a normal corneal light reflex? a. The eye focuses the image in the center of the pupil b. The eyes converge to focus on the light c. Constriction of both pupils occurs in response to bright light d. Light is reflected at the same spot in both eyes When testing visual fields, the nurse is assessing a. Peripheral vision b. Near vision c. Distance vision d. Central vision d. Patient speaks in a very loud voice Which assessment finding could indicate hearing loss? a. Patient converses easily with nurse b. Patient answers questions appropriately c. Patient’s face is relaxed during conversation d. Patient speaks in a very loud voice Which of the following tests would the nurse use as an initial screening for hearing loss? a. Romberg test b. Otoscopic examination c. Caloric test d. Whisper voice test Which of the following would the nurse use to document a finding that the patient’s ear is draining? a. Otorrhea b. Otalgia c. Ototoxic d. Tinnitus A nurse is caring for a patient who has a history of acute angle-closure glaucoma and is scheduled for surgery. Which of the following medication orders should the nurse clarify to prevent serious eye complications? a. Morphine b. Cefazolin (Kefzol) c. Atropine d. Ranitidine (Zantac) The nurse is contributing to the plan of care for a patient with Menieres disease. Which one of the following is the primary goal for a patient with Menieres disease that the nurse should recommend be included in the plan of care? a. Prevent dehydration b. Decrease pain c. Prevent injury d. Preserve hearing B. The patient’s lack of proprioception Ms. Small has sustained a brain attack (stroke/CVA). The nurse notes that the patient is having difficulty placing her affected leg in the correct position when ambulating. This is most likely due to which of the following? A. Poor directions given to the patient by the physical therapist B. The patient’s lack of proprioception C. Impaired blood flow to the affected leg D. The patient’s resistance to therapy C. Close blinds, dim lights, & ask pt what other measures would help him rest Mr. Arbor complains to nurse that he's feeling anxious. He states, “I’m just so tired of all these tests they're doing, & it’s so noisy here at night.” Pulse is 110 bpm, BP is 140/70. Nursing actions should include what to address sensory status? A. Turn on TV/radio in room so it will distract him B. Have therapist ambulate pt to walk off his anxiety C. Close blinds, dim lights, & ask pt what other measures would help him rest D. Call physician & obtain an order for an anti-anxiety medication for PRN use A. Identify yourself when you enter room & tell him the day/time Timothy is hospitalized in a coma following traumatic brain injury. Nursing care would include which of following? A. Identify yourself when you enter room & tell him the day/time B. Tape eyelids closed securely to prevent drying of corneas C. Limit families involvement in care so there is more consistency D. Avoid touching patient, because this will increase his irritability True or False: Cleaning a patient’s hearing
aid is a nursing action that will have a positive effect on a sensory deficit. False. Loss of smell is termed anosmia. Xerostomia is dry mouth. True or False: Xerostomia is the term for loss of smell. False. True or False: The priority treatment for a patient experiencing acute confusion would be the administration of IV haloperidol (Haldol). True or False: Loss of hearing can put a patient at risk for social isolation. A patient must place his hand on the wall to keep his balance when walking. He leans when sitting and has difficulty knowing when his body is vertical and sensing the position of his body in space. Which type of receptor is probably involved? 1) Photoreceptors Which medication might blunt a patient's perception of various kinds of stimuli? 1) Furosemide (Lasix) A patient complains, "Everything tastes so bland. I add salt, pepper, and sugar to everything just to make it so I can taste it." Which nutrient deficiency might be responsible for his problem? Select all that apply. 1) Vitamin A After sustaining an eye injury in a baseball game, a patient complains of blurred and distorted vision. Which visual deficit is this patient most likely experiencing? 1) Macular degeneration Pt unable to sleep for several nights has experienced change in mental status. He does not
know what day it is, or where he is. Speech & movements are slowed, he seems dazed & stupefied. He cannot follow simple directions such as, "Hold out your hand." Which nursing diagnosis is most appropriate for this patient? 3) Provide aromatherapy for him A patient in a nursing home is deaf and nearly blind. He is confined to bed most of the time. Which of the following interventions would help to promote optimal sensory function? b. Will report pain at 4 or less on a 10-point scale. Your assigned first day post-operative client, who has a new colostomy, seems to worry a lot and has symptoms of sensory overload. Which of the following client goals, if met, would most contribute to reducing sensory overload for this client? a. Will not sleep or nap during the day. b. Will report pain at 4 or less on a 10-point scale. c. Will attend classes on colostomy care. d. Will look at colostomy during colostomy care. a. Disorientation is normal reaction to sudden blindness. The nurse is admitting person who had a sudden loss of eyesight & finds that the client is disoriented. The nurse will most suspect which of following about the disorientation? a. Disorientation is normal reaction to sudden blindness. b. Compensatory behavior to eyesight loss includes disorientation. c. Client will compensate for eyesight loss w/in 48 hrs. d. Disorientation is a symptom of cause of sudden eyesight loss. When gathering data to assist with assessments of clients, you will find which of the following clients most at risk for sensory overload? a. a client in pain b. a homebound client c. a client on bed rest d. a client in isolation b. Explain the sounds in the environment. A client has some noisy equipment, the roommate also has equipment that makes noise, & the room is close to a noisy nursing station, where they can be watched a little closer. Which of following interventions by nurse would be best for client as well as reduce risk of sensory overload? a. Move the client away from nurses' station area. b. Explain the sounds in the environment. c. Tell client to ignore the sounds. d. Play client's favorite music louder than the sounds. While performing a history, the nurse assesses sensory perceptions such as: Peripheral neuropathy and paresthesias become the etiology for
other nursing diagnoses. An example of such a diagnosis is: d. Allows newborn to nurse w/in minutes of birth A nurse promotes healthy sensory function for infants when the nurse: c. Establishing a routine identified with each meal Nurses can increase environmental stimuli for clients with sensory deficit by: c. Keeping the room pathways free of clutter A client has impaired vision. An intervention to best adapt the environment to this loss includes: b. "I can't hear people knocking at the door." Which statement by a client with decreased hearing indicates a need for a sensory aid in the home? Which of the following questions would be easiest for a client with a hearing deficit to understand? c. "I'm tired of sitting in this train station." Which statement by a hospitalized client indicates she needs further orientation to time, place, person, or situation? b. A deaf 88-year-old single client w/ +4 edema who lives in an upstairs apartment Which client is most likely to experience sensory deprivation? a. “These clients don't have any idea what's going on.” Which statement made by a graduate nurse who is assigned to work on unit w/clients who have cognitive impairments is cause for concern? a. “These clients don't have any idea what's going on.” b. “I don’t feel safe around clients who hallucinate.” c. “I need to learn more
about cognitive disorders so I can better care for the clients.” d. “I will ask other staff for suggestions on therapeutic interventions with the clients.” d. “I'll put notes on the different rooms of house so my father remembers what room he's in.” A father is experiencing memory lapses associated w/early-onset DAT. The nurse knows family
members understand teaching about memory problems when the individual states: a. “I'll keep Dad in house so he doesn't get lost.” b. corneaa. a. aqueous humor c. lens d. vitreous humor In what order does a beam of light pass through the refractive structures in the eye? Use all items and place them in correct order. a. aqueous humor b. cornea c. lens d. vitreous humor d. comparing pt's visual fields with the nurse's own visual fields Which of the following methods can be used to assess visual fields? a. inspection with ophthalmoscope b. fluorescein angiography c. testing vision with Snellen chart d. comparing pt's visual fields with the nurse's own visual fields b. is irritable or sensitive in interpersonal relations Which of following pt behaviors would the nurse expect to find in the health history of a pt who has a hearing loss? a. turns volume lower on the TV b. is irritable or sensitive in interpersonal relations c. answers questions appropriately d. mentions that people talk too loudly c. When was your last hearing evaluation? The nurse is collecting data during a pt's clinic visit. Which question will best collect data about a pt's preventive ear health? a. What symptoms are you having? b. Tell me about your ear pain. c. When was your last hearing evaluation? d. What medications do you take? Which of following is most important nursing intervention during Romberg's test? a. Ensure pt safety b. Whisper softly into each ear c. Ensure a quiet environment d. Remove all cerumen from ear canal d. Aspirin can be toxic to the ears. Which of following pt statements indicates understanding of ear care teaching? a. I should insert a cotton swab into my ear canal for cleaning. b. I should not get my external ear wet during bathing. c. I should block one nostril when blowing my nose. d. Aspirin can be toxic to the ears. a. gloves b. gown c. goggles The nurse prepares to provide an eye irrigation to a pt w/MRSA infection. Contact precautions are ordered. Which of following protective items will nurse need while performing this procedure? Select all that apply. a. gloves b. gown c. goggles d. mask e. shoe protectors f. sterile gloves A pt is taking aspirin. Which of following findings would indicate to the nurse that the pt is experiencing a toxic effect related to the medication? a. halos around lights b. decreased night vision c. tinnitus d. vertigo c. Hardening of the stapes due to new bone growth. A pt is diagnosed w/otosclerosis and asks the nurse what this disease is. Which of following is most appropriate response by nurse? a. Infection of the external ear commonly caused by moisture. b. Tumor of the eighth cranial nerve. c. Hardening of the stapes due to new bone growth. d. Inflammation of the inner ear caused by pathogens. b. You'll need corrective lenses in order to see clearly. Pt is diagnosed w/refractive error and asks the nurse what this means. What would be appropriate explanation by nurse? a. You will lose your vision and become blind. b. You'll need corrective lenses in order to see clearly. c. The pressure in your eyes is higher than normal. d. Your vision is 20/20. A pt comes to the health clinic for a suspected ear infection. Which of the following data collection finding does the nurse expect w/an external ear infection? a. pain b. fullness in ears c. fever d. dizziness a. Wear sunglasses after the exam. A pt has been prepped for an internal eye exam. Anesthetic drops as well as mydriatic drug have been administered. Which of following should pt be taught for eye safety following exam? a. Wear sunglasses after the exam. b. Rub your eye hourly to increase blood circulation. c. You may reapply contact lenses when the eye exam is complete. d. Flush your eye w/water to remove eyedrops. b. 30 year old woman after pneumatic retinopexy The nurse understands that which of the following patients needs specific positioning instructions
postprocedure to prevent complications? a. 19 year old after removal of congenital cataract b. 30 year old woman after pneumatic retinopexy c. 52 year old man after trabeculectomy d. 82 year old man after corneal transplant c. atropine Atropine and hydroxyzine are mydriatics, which are contraindicated in acute angle-closure glaucoma to prevent increasing eye pressure. Which of following meds should nurse question before giving to prevent serious eye complications for a pt who has a history of acute angle-closure glaucoma? Select all that apply. Which of following meds can cause hearing
loss? d. loss of central vision Which of following symptoms would nurse expect to be in the history of a pt who has macular degeneration? c. prevent injury Meniere's disease can cause vertigo, which could result in injury. Which of following is primary goal for a pt w/ Meniere's disease that nurse should recommend be included in plan of care? Nurse is caring for pt w/presbycusis. Which of following techniques would be most important for nurse to use to increase communication w/pt? d. diphenhydramine (Benadryl) Pt w/acute angle-closure glaucoma reports use of following meds. Using which of these medications indicates to nurse that further instruction is needed? |
A nurse is caring for a client who had a stroke and reports difficulty with proprioception
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