Deck 18: Sensory Perception

Question 1

A nurse is evaluating the care received by a client who has a hearing deficit. Which statement indicates that the client is effectively addressing variables that may lead to social isolation?

A)"I ask others to face me when they talk because I can hear them better."
B)"I keep the television volume raised to a high level."
C)"I don't use my hearing aid unless someone seems to need to talk to me."
D)"I might use the hearing aid when I go shopping."

Answer 1

"I ask others to face me when they talk because I can hear them better."

Question 2

The nurse is selecting sensory aids for a client with deficits in hearing and sight. Which aid would address both sensory deficits?

A)Adequate room lighting with night lights
B)Flashing alarm clock with large numbers
C)Amplified telephone
D)Large-print reading material

Answer 2

Flashing alarm clock with large numbers

Question 3

What is vertigo?

A)Involuntary rapid eye movements
B)A feeling of rotation or imbalance
C)An infection of the vestibular nerve
D)Impaired olfaction

Answer 3

A feeling of rotation or imbalance

Question 4

Which diagnostic test should the nurse use to assess hearing in an infant?

A)Otoacoustic emissions test
B)Weber test
C)Rinne test
D)Whisper test

Question 5

What characterizes individuals with achromatopsia?

A)They perceive only the secondary colors of purple, orange, and green.
B)They perceive only the primary colors of red, blue, and yellow.
C)They perceive some colors as indistinguishable from other colors.
D)They perceive only shades of gray and no colors.

Question 6

Which strategy for communication enhancement incorporates the use of shapes?

A)Sign language
B)Oral approach
C)Total communication
D)Cued speech

Question 7

A nurse is caring for a client with a genetic nerve disorder who has difficulty when attempting to move her tongue. The nurse recognizes that this may indicate a deficit in the functioning of which cranial nerve?

A)XII
B)XI
C)VIII
D)VI

Question 8

The nurse is planning care for an older adult client diagnosed with age-related macular degeneration (AMD)that is nonexudative. Which therapies should the nurse anticipate for this client? Select all that apply.

A)Laser surgery
B)Eye patches
C)Antioxidants
D)Eyedrops
E)Zinc

Question 9

Which is the decibel level for mild hearing loss?

A)16-40 dB
B)41-70 dB
C)71-90 dB
D)91+ dB

Question 10

The nurse is providing teaching on the recommended hearing tests for older adults. Which information should be included in this teaching?

A)Schedule an annual hearing test until the age of 50 and then have a test every 6 months.
B)Annual screenings are recommended for adults with diabetes.
C)For individuals without comorbidities, hearing exams should be repeated every 1-3 years for ages 55-64, and every 1-2 years for ages 65 and above.
D)Have a hearing test every 10 years until age 50 and then every 3 years.

Question 11

Which nursing action is most appropriate when communicating with a client who has a hearing deficit?

A)Drawing out the articulation of words with extra emphasis in order for the client to understand
B)Using shorter phrases, which tend to be easier to understand than longer ones
C)Varying the volume of voice, which is easier to understand than one consistent volume
D)Writing ideas or pantomiming as appropriate in order for the client to understand

Question 12

A nurse is providing teaching to a young adult client who is occasionally exposed to loud explosions on the job site. Which statement on the part of the client indicates that he accurately understands the potential risk to his hearing?

A)"If my hearing is damaged on the job, I can have surgery to fix it."
B)"Hearing loss from exposure to loud noises actually has a genetic component."
C)"Damage to the ear from loud noises can cause permanent hearing loss."
D)"Hearing loss attributed to loud noises is normally reversible, especially in younger people."

Question 13

What are the two components of the sensory process?

A)Stimulus and receptor
B)Kinesthesia and stereognosis
C)Visual and auditory
D)Reception and perception

Question 14

Which client should the nurse identify as having the greatest risk for hearing loss?

A)Construction worker who typically works in urban centers
B)Adolescent who occasionally listens to loud music on headphones
C)Teacher who works at a large high school
D)Lawyer who enjoys snowmobiling once a year

Question 15

The nurse suspects that an older adult client has a hearing disorder; however, the client denies not being able to hear, and the family thinks the client is just becoming more absent minded with age. Which initial action by the nurse to assess the client's hearing is appropriate?

A)Use an otoscope to visualize the inner ear.
B)Schedule a Weber and Rinne test.
C)Confront the client with the suspicion.
D)Observe the client's interaction with family.

Question 16

A client is experiencing visual overstimulation. What can the nurse do immediately to reduce this client's visual sensory overload?

A)Suggest the client wear sunglasses that block UVA rays only.
B)Reduce the amount of light in the room by lowering shades and turning off overhead lights.
C)Provide the client with large-print reading materials.
D)Encourage the patient to employ relaxation techniques to reduce anxiety and stress.

Question 17

The nurse is identifying nursing diagnoses appropriate for a client with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. Which diagnosis would be the lowest priority for this client?

A)Impaired Verbal Communication
B)Social Isolation
C)Nausea
D)Risk for Injury

Question 18

Where does perception, or the awareness and interpretation of stimuli, take place?

A)The brain
B)The nerve receptors
C)The peripheral nervous system
D)The impulses

Question 19

A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper. Which tool should the nurse select to assess this client?

A)Rosenbaum eye chart
B)Penlight
C)Cover-uncover test
D)Snellen eye chart

Question 20

The nurse is conducting a prenatal assessment on a client. Which finding indicates a risk of sensory impairment in the unborn child?

A)Lack of immunity to rubella
B)History of otitis media
C)Immunity to varicella
D)Brief case of moderate conjunctivitis

Question 21

Which assessment finding is consistent with a diagnosis of open-angle glaucoma?

A)A client loses vision intermittently several times over the course of several hours.
B)A client has an episode of lost vision when experiencing a panic attack.
C)A client loses the ability to see at all during a city-wide blackout.
D)A client experiences gradually diminishing vision in both eyes over an extended period.

Question 22

What is conductive hearing loss?

A)Degeneration of the hair cells of the cochlea
B)Damage to the hair cells of the organ of Corti
C)Disruption of the transmission of sound from the external auditory meatus to the inner ear
D)Decrease or distortion in the ability of the inner ear to receive and interpret auditory stimuli

Question 23

An older adult client is using prescription eyedrops to treat her glaucoma. When providing client teaching about this medication, which of the following should the nurse mention as potential side effects? Select all that apply.

A)Blurred vision
B)Intermittent loss of eyesight
C)Headaches
D)Clouding of the eyes
E)Change in eye color

Question 24

Which diagnostic technique is used to confirm the location and extent of cataracts?

A)Visually inspecting the optic fundus using an ophthalmoscope
B)Using tonometry to indirectly measure intraocular pressure
C)Revealing a dark area instead of the red reflex through ophthalmoscopy
D)Identifying patient history consistent with risk of cataracts and examining the eye to diagnose the cataract

Question 25

An older adult client with bilateral cataracts, arthritis, and a hearing deficit is scheduled for cataract surgery. Which is the priority nursing diagnosis for this client?

A)Disturbed Body Image
B)Decisional Conflict: Cataract removal
C)Risk for Ineffective Health Maintenance
D)Ineffective Coping

Question 26

A school nurse is identifying students who may have hearing loss. Which student would the nurse be most concerned about?

A)A child who startles easily at loud noises
B)A child who gets annoyed when things like televisions are too loud
C)A child who cannot follow conversations in the hallways between classes or in the cafeteria
D)A child who likes to listen to music on earbuds

Question 27

A nurse is caring for a client who is receiving IV tobramycin for the treatment of a respiratory infection. Which of the following should the nurse plan on teaching the client how to do?

A)Understand the actions and drug interactions of aminoglycosides.
B)Self-monitor for hearing loss.
C)Use total communication.
D)Understand cued speech.

Question 28

A nurse is caring for several pediatric clients who are affected by cataracts. Of these clients, which is the most obvious candidate for surgical removal of the cataract?

A)Two-month-old infant who is asymptomatic
B)Six-month-old infant with difficulty noticing toys or faces
C)Three-month-old infant with diminished reaction to bright light
D)One-month-old infant with no reaction to bright light and failure to notice toys or faces

Question 29

A client is undergoing surgery to manage glaucoma. When providing postoperative teaching to this client, the nurse should emphasize that the client is now at increased risk for which form of cataracts?

A)Congenital
B)Secondary
C)Radiation
D)Traumatic

Question 30

Which of the following diagrams would the nurse use when describing open-angle glaucoma to a client?

A)A diagram showing a completely closed anterior chamber angle
B)A diagram showing a completely occluded outflow of aqueous humor
C)A diagram showing a blockage of the trabecular meshwork and canal of Schlemm
D)A diagram showing congestion of the trabecular meshwork and reduced flow of aqueous humor through the canal of Schlemm

Question 31

Which assessment finding supports the nurse's conclusion that a client is at risk for cataracts?

A)Age 75 years
B)Hypertension
C)Moderate alcohol use
D)Smoker

Question 32

A nurse is working with several clients who are experiencing hearing loss. Of these clients, which is the best candidate for a cochlear implant?

A)A client with a perforated tympanic membrane
B)A client with sensorineural hearing loss from long-term exposure to loud noise
C)A client with an obstruction of the external ear canal
D)A client with a tumor of the middle ear

Question 33

What is characteristic of conductive hearing loss?

A)For loss of hearing to be the same at all frequencies
B)For loss of hearing to primarily involve the upper frequencies
C)For loss of hearing to primarily involve the middle frequencies
D)For loss of hearing to primarily involve the lower frequencies

Question 34

The nurse is planning care for a client scheduled for cataract surgery. Which intervention should the nurse include in the plan of care to help provide a safe environment for the client following surgery?

A)Ensuring fall hazards are removed from the client's home and additional lighting is provided
B)Educating the client about what self-care activities are necessary following surgery
C)Making the client's close family aware of the self-care instructions the client has received
D)Ensuring the client's employer does not expect the client to return to standard duties until clearance for such activities by the healthcare provider

Question 35

A client has been diagnosed with cataracts of both eyes. The client's vision and activities of daily living have become severely impaired. What collaborative intervention does the nurse anticipate for this client?

A)Corrective lenses for the cataracts
B)Two surgical procedures, separated by a few weeks, to remove the cataracts
C)Two surgical procedures to remove both cataracts at the same time
D)Eyedrops to treat the cataracts

Question 36

The nurse is providing teaching to a client who was prescribed an ophthalmic beta blocker for glaucoma. The client is having difficulty understanding how to self-administer the medication. Which instruction by the nurse is best?

A)"Occlude your lacrimal duct."
B)"Close your eyes."
C)"Guard against systemic absorption."
D)"Use punctal occlusion."

Question 37

After being diagnosed with cataracts, a client believes the right eye has a cataract but not the left eye, as there are no vision changes with the left eye. Which response by the nurse is accurate?

A)"Only your doctor can tell if you have a cataract in your left eye."
B)"Cataracts develop at different rates, so one eye may be more affected than the other."
C)"The changes being confined to one eye indicate a less severe cataract."
D)"Surgery is still necessary for both eyes."

Question 38

Which of the following best describes tinnitus?

A)A ringing sound accompanying perception of high-frequency tones
B)Auditory perception from visual stimuli
C)Lack of auditory perception of external auditory stimuli
D)Auditory perception without external auditory stimuli

Question 39

The nurse is planning care for a client with glaucoma who is experiencing anxiety as a result of the diagnosis. Which intervention should the nurse select to address this need?

A)Assure the client there is nothing to be afraid of.
B)Support the client's use of coping mechanisms.
C)Turn off the lights when leaving the client's room.
D)Refer the client to a counseling psychologist.

Question 40

The nurse is evaluating instructions provided to a client with glaucoma. Which client statement indicates that teaching has been effective?

A)"The eyedrops only need to be used when my eyes hurt."
B)"I can stop the eyedrops when the glaucoma has resolved."
C)"I must use my eyedrops as prescribed for the rest of my life."
D)"I will need to continually increase the dose of my eyedrops."

Question 41

A client comes into the emergency department with an eye injury. Which assessment findings suggest that this injury is the result of blunt trauma? Select all that apply.

A)Lid ecchymosis
B)Eye pain and decreased sharpness of vision
C)Photophobia and eye tearing
D)A well-defined bright area of erythema under the conjunctiva
E)A feeling of something in the eye

Question 42

The nurse is preparing discharge instructions for a client with age-related macular degeneration (AMD)and type 1 diabetes mellitus. What should the nurse include in this client's teaching plan?

A)Information on assisted-living facilities
B)Information on the need to have routine eye examinations every 5 years
C)Referral to home care to ensure safety with administering insulin and AMD medications at home
D)Information on Stargardt disease

Question 43

Which best describes photophobia?

A)Fear of light
B)Aversion to light
C)Reactive to light
D)Need for light

Question 44

An older adult client with intermediate dry macular degeneration calls the nurse complaining that his vision is suddenly much more distorted and colors do not seem right. Which action by the nurse is priority?

A)Talk with the client to assess for other hallucinations that might be occurring.
B)Check the client's medications for side effects of vision changes.
C)Ensure the client's safety by raising the bedrails.
D)Contact the healthcare provider for an immediate ophthalmologic evaluation.

Question 45

The nurse is planning instruction for a client who is newly diagnosed with glaucoma. What should be included in this teaching? Select all that apply.

A)Manage eye pain with over-the-counter analgesics.
B)Clouding of the affected eye(s)is expected.
C)Self-administer prescribed eye medication properly.
D)Attend follow-up appointments with the physician.
E)Avoid over-the-counter medication unless discussed with the physician.

Question 46

The nurse is caring for a client who recently sustained a blow to the head. Which of the following assessment findings suggest that the client should be more closely evaluated for retinal detachment?

A)Eye pain and redness
B)Floaters in the visual field
C)Subconjunctival hemorrhage
D)Hyphema

Question 47

The nurse is caring for a client in the early stage of macular degeneration. What dietary changes should the nurse recommend to slow the progression of the disease?

A)High-antioxidant diet
B)Low-antioxidant diet
C)Low-fat diet
D)High-fat diet

Question 48

A client is receiving verteporfin treatment for macular degeneration. The client asks the nurse what the expected outcome of treatment is. Which response by the nurse is most appropriate?

A)It will increase the effectiveness of surgery.
B)It will reverse the effects on the disease.
C)It will promote the development of new blood vessels.
D)The progression of the disease will be slowed.

Question 49

What class of drugs both decreases production of aqueous humor in the eye and increases drainage of aqueous humor from the uveoscleral pathway?

A)Beta-adrenergic blockers
B)Prostaglandin analogs
C)Alpha?-adrenergic agonists
D)Cholinergic agonists

Question 50

The nurse is caring for a client who has been using timolol (Timoptic)to manage glaucoma. Which assessment finding supports an adverse effect associated with systemic absorption of the drug?

A)Eye pain
B)Heart rate of 57
C)Urinary frequency
D)Blurred vision

Question 51

The home care nurse is assessing a client with macular degeneration. What interventions would be appropriate to ensure home safety for this client? Seslect all that apply.

A)Keep the stairs free of clutter.
B)Wear socks without shoes when walking in the home.
C)Use one electrical outlet for devices.
D)Have grab bars installed in the bathroom.
E)Remove scatter rugs from the floors in the home.

Question 52

Which of the following clients most likely will require assistance with properly taking medications for macular degeneration?

A)72-year-old client, no dementia, no arthritis, hypertension
B)67-year-old client, dementia, arthritis, no hypertension
C)47-year-old client, no comorbidities
D)52-year-old client, gastroesophageal reflux disease (GERD), hypertension

Question 53

Which of the following scenarios is consistent with secondary congenital glaucoma?

A)A newborn is diagnosed with glaucoma at birth.
B)An infant is diagnosed at 6 months with glaucoma.
C)A 1-year-old infant develops glaucoma following neurofibromatosis.
D)A 5-year-old child is diagnosed with glaucoma.

Question 54

Which client is most at risk for eye injuries?

A)A firefighter who wears all required safety gear on calls
B)A baseball player who wears nothing over the eyes
C)A self-employed home worker who wears ANSI Z87 eyewear when doing any household cleaning or yard work
D)A construction worker who wears OSHA-required eyewear at all times while on site

Question 55

An older adult client tells the nurse that reading is easier when the material is held to the left or right. What should the nurse suspect this client is experiencing?

A)Cataract
B)Detached retina
C)Exudative macular degeneration
D)Nonexudative macular degeneration

Question 56

A nurse working in the emergency department is caring for a client with an eye injury. The client describes spots in the field of vision. Based on this finding, which of the following is the nurse's priority concern?

A)The possibility that the client will immediately lose all vision
B)The possibility that the client will experience a progressive deterioration of vision
C)The possibility that the client will begin to experience intense eye pain
D)The possibility that the client's conjunctiva will become red and edematous

Question 57

A nurse is caring for a client with glaucoma who is prescribed an ophthalmic beta-adrenergic blocking agent. When teaching the client about the therapeutic action of this medication, which of the following statements should the nurse include?

A)"This drug reduces pressure in the eye by relaxing the muscles of the eye."
B)"This medication only needs to be taken when eye pain is experienced."
C)"Systemic absorption may occur, resulting in hypotension, bradycardia, and shortness of breath."
D)"This drug reduces intraocular pressure by decreasing the production of fluid in the eye."

Question 58

The nurse is providing teaching to a client related to maintaining healthy vision. Which of the following should the nurse identify as a modifiable risk factor for macular degeneration?

A)Caucasian ancestry
B)Smoking 1 pack of cigarettes per day
C)62 years of age
D)Family history of AMD

Question 59

Laser surgery and photodynamic therapy are both treatments for what disease of the eye?

A)Congenital cataracts
B)Age-related cataracts
C)Nonexudative macular degeneration
D)Exudative macular degeneration

Question 60

Which statement about cataract surgery is correct?

A)Cataract surgery should be quick but may have to take place in stages.
B)Cataract surgery may only be done on an inpatient basis with general anesthesia.
C)Cataract surgery is not recommended except in cases of opacification of the remaining posterior capsule.
D)Cataract surgery is typically bilateral and can be performed in a single day.

Question 61

Which statement is true?

A)Eye injuries almost always take place in the home.
B)Construction workers have a reduced risk of eye injury because of the many protective measures they take.
C)The pathophysiology of an eye injury depends on the nature of the injury.
D)Eye injuries are relatively uncommon with advances in safety and risk prevention.

Question 62

The nurse is planning a teaching seminar for parents of school-age children that focuses on eye safety. What should the nurse include in this educational session?

A)All children should wear goggles when playing outdoors at all times.
B)Sunglasses need only be worn during the summer months.
C)Supervise young children when lighting fireworks.
D)Keep sharp objects out of the reach of young children.

Question 63

A client presents in the emergency room with a penetrating eye injury. The object is still present in the eye. Which nursing action is priority?

A)Apply anesthetic drops.
B)Apply eye ointment.
C)Remove the object.
D)Stabilize the object.

Question 64

Which degree of alcohol use has been implicated in the development of alcohol-related neuropathy?

A)Chronic and heavy
B)Short term and light
C)Intermittent and severe
D)Acute and toxic

Question 65

The nurse is caring for a client who receives vitamin B₁₂ injections to control her peripheral neuropathy. The client tells the nurse that she recently started experiencing increased tingling in her fingers and toes, and she asks the nurse what this means. How should the nurse reply?

A)"The tingling suggests that you are due for another injection."
B)"The tingling means that the injections are not producing their intended effect."
C)"The tingling is a common side effect of B₁₂ injections."
D)"The tingling is most likely unrelated to your injections."

Question 66

The nurse is planning care for an adolescent client recently diagnosed with Charcot-Marie-Tooth syndrome. Which intervention is the highest priority?

A)Managing the client's chronic pain
B)Reducing the client's risk for injury
C)Addressing the client's perfusion problems
D)Relaxing the client to reduce stress

Question 67

The nurse is planning teaching for a client diagnosed with diabetic neuropathy. What should the nurse include in this teaching?

A)Set the water heater at 120°F.
B)Avoid hand and foot massages.
C)Use a mirror to inspect feet daily.
D)Increase medication for pain as necessary.

Question 68

A client with a long history of type 2 diabetes mellitus complains of occasional coldness and numbness in both hands and both feet. These complaints are suggestive of which condition?

A)Idiopathic peripheral neuropathy
B)Mononeuropathy
C)Polyneuropathy
D)Hereditary peripheral neuropathy

Question 69

Which client's clinical manifestations are most consistent with Guillain-Barré syndrome?

A)A 13-year-old client feels weakness in the feet, ankles, and legs.
B)A 5-year-old client feels leg pain and wants to be carried.
C)A 55-year-old client experiences a lack of hand strength.
D)A 23-year-old client with peripheral neuropathy has poor glycemic control.

Question 70

Which of the following statements regarding idiopathic neuropathy is true?

A)Idiopathic neuropathy is hereditary in nature.
B)Idiopathic neuropathy has no known cause.
C)Idiopathic neuropathy is caused by nutritional deficits.
D)Idiopathic neuropathy is caused by disease or illness.

Question 71

The nurse is providing teaching to an older adult client related to avoiding eye injury. What should the nurse identify as an intervention to address the number-one cause of eye injuries in older adults?

A)Turning down the temperature of the client's home water heater
B)Storing all harsh chemicals out of easy reach
C)Ensuring the client wears protective goggles when engaging in outdoor activities
D)Addressing slippery floors and other fall hazards in the client's home

Question 72

Which of the following statements best describes the physiologic response of the layers of the eye in response to a penetrating injury?

A)They pull away from the penetration.
B)They reform following the penetration.
C)They degenerate and atrophy immediately.
D)They begin to tear away from one another.

Question 73

Foreign objects commonly cause what type of injuries among migrant farm workers?

A)Burns
B)Blunt trauma
C)Penetrating trauma
D)Abrasions

Question 74

A client recovering from a penetrating eye injury tells the nurse that some shadows and movement can be seen with the eye. Based on this data, what should the nurse do next?

A)Note a deterioration in vision.
B)Administer ultrasonography to assess the eye for a detached retina.
C)Compare this data to the initial assessment.
D)Note an improvement in vision

Question 75

The nurse is providing client teaching on Guillain-Barré syndrome. Which explanation for a client's false perception that socks are being worn is accurate?

A)Confusion is a part of this disorder, so the client is simply confused as to whether socks are being worn.
B)This disorder causes a change in sensation that makes the client feel as if socks are being worn.
C)The medications used to treat this disorder cause the client to feel as if socks are being worn.
D)Tactile hallucinations are part of this disorder, so the client is hallucinating that socks are present.

Question 76

A client is diagnosed with a detached retina. Which is the priority nursing diagnosis for this client?

A)Risk for Infection
B)Anxiety
C)Acute Pain
D)Risk for Injury

Question 77

The nurse is caring for a client with a corneal abrasion. Which collaborative intervention should the nurse anticipate being included in the client's care?

A)Bedrest and an eye shield
B)Surgery
C)Applying antibiotic ointment and an eye shield
D)Flushing the eye with normal saline

Question 78

The nurse is providing teaching to a client at risk for acquired peripheral neuropathy. Which of the following activities should the nurse suggest the client modify or avoid to reduce the risk of this condition?

A)Working as an automobile mechanic on weekends
B)Playing tennis every Saturday
C)Drinking one six-pack of beer per day
D)Typing on the computer for several hours each day

Question 79

What does it mean to say that a corneal abrasion causes a disruption of the superficial epithelium of the cornea?

A)Such injuries are typically painless.
B)The superficial epithelium is completely removed.
C)The integrity of the superficial epithelium is disturbed.
D)The surface of the cornea sustains penetrating trauma.

Question 80

A client with peripheral neuropathy complains of leg aches and the inability to be comfortable. Which nursing diagnosis would be a priority for the client at this time?

A)Anxiety
B)Ineffective Peripheral Tissue Perfusion
C)Ineffective Coping
D)Chronic Pain