Deck 31: Sensory Function

Question 1

Your 88-year-old client is hospitalized for a retinal detachment.He is on bed rest, and both eyes are covered with patches.Which nursing diagnosis takes priority at this time?

A)Self-esteem disturbance related to decreased independence
B)High risk for altered thought processes related to visual impairment
C)High risk for injury related to altered sensory perception
D)Impaired social interaction related to visual deficit

Answer 1

High risk for injury related to altered sensory perception

Question 2

An older adult client reports "ringing" in her ears.What additional data should the nurse gather to help determine the cause of the client's problem?

A)History of ear surgery
B)Use of prescription medications
C)Exercise and sleep patterns
D)Nutritional status, especially protein intake

Answer 2

Use of prescription medications

Question 3

An older adult diagnosed with Ménière's disease is prescribed meclizine (Antivert) and hydrochlorothiazide (HCTZ).The nurse's educational instructions include which of the following? Select all that apply.

A)The need to avoid alcoholic beverages
B)Instructions to take the medication with food
C)Symptoms of electrolyte imbalances
D)That drowsiness is a common side effect
E)Stopping the medication if chest pain occurs

Answer 3

The need to avoid alcoholic beverages
Symptoms of electrolyte imbalances
That drowsiness is a common side effect

Question 4

A 96-year-old client reports symptoms xerostomia.The nurse attempts to minimize the effects of the condition by:

A)providing appropriate fluids with the client's meals.
B)cutting the client's meat into small bite-size pieces.
C)elevating the head of the client's bed at meal times.
D)assisting the client with oral care before each meal.

Question 5

The preferred way for the nurse to communicate with a 72-year-old hearing-impaired client is to:

A)speak loudly into the client's unaffected ear.
B)exaggerate the form of each word.
C)provide all communication in written form.
D)speak clearly and directly, facing the person.

Question 6

An older adult client reports burning and itching eyes.On assessment, the nurse notes swelling of the eyelid margins bilaterally.What additional data are necessary to confirm the nurse's suspicion of blepharitis?

A)The client reports visual disturbances such as rainbow halos.
B)The eyelids are reddened from seborrhea.
C)The client is being treated with anticoagulants.
D)Small corneal hemorrhages are present.

Question 7

The morning of his scheduled cataract extraction and intraocular lens placement of the right eye, an older adult client expresses concern that he will not remember his instructions for home care.Which statement is the best response to the client's concern?

A)"Is your family going to be here while you're in surgery?"
B)"Are you anxious about the surgery?"
C)"I'll re-enforce the important points."
D)"We will provide you with written instructions."

Question 8

An older adult's chart documents that she has been diagnosed with macular disequilibrium.Based on an understanding of this condition and the resulting vertigo, the nurse suggests that the client:

A)turn her head very slowly when looking from right to left.
B)dangle her legs at the bedside before getting out of bed.
C)use the wall for stabilization when ambulating in the hallway.
D)be careful to be seated when flexing or hyperextending her neck.

Question 9

A 77-year-old client who is quiet and withdrawn may have a hearing deficit related to impacted cerumen.During the nursing assessment the nurse confirms supporting evidence of the condition when noting:

A)frothy drainage from the client's ears.
B)client reports of dizziness.
C)client statement of having a feeling of fullness in his ears.
D)gray, metallic-appearing tympanic membrane.

Question 10

A 66-year-old client has been diagnosed with type 2 insulin-dependent diabetes mellitus.When discussing vision related complications the nurse recognizes that the client has an understanding of symptom management when she states that she lost most of her vision as a result of diabetic retinopathy.Which behavior indicates that she may be having difficulty adapting to her diminished vision?

A)"I schedule my yearly eye examination for the week of my birthday"
B)"When I notice haloes around lights I'll know I'm developing a problem with retinopathy."
C)"My sister had diabetic retinopathy and the vessels in her eyes were scarred."
D)"I understand that the eye problems need to be diagnosed with an ophthalmoscopic exam."

Question 11

When assessing the client's vision, the nurse should understand that older adults may report common aging changes including which of the following? Select all that apply.

A)"My eyelids droop so unattractively."
B)"The whites on my eyes seem a bit yellow."
C)"The vision in my right eye seems blurry."
D)"I've started to use over the counter eye moisturizing drops."
E)"I have noticed the night driving has become more difficult."

Question 12

An older client with presbycusis has been advised to purchase a hearing aid and asks about its function and use.Which information is most accurate to give the client about the function of hearing aids?

A)Hearing aids amplify sound but do not improve the ability to hear.
B)Hearing aids improve the ability to hear by intensifying the duration of sound waves.
C)Hearing aids control the input of sound waves to eliminate extraneous noise.
D)Hearing aids intensify sound waves and improve the ability to hear.