Deck 39: Sensory Alterations

Question 1

How can the nurse assess if an infant is experiencing hearing loss?

A) Use an otoscope to ensure that the infant's tympanic membrane is intact.
B) Review the infant's medication list for medications that cause ototoxicity.
C) Examine the infant's outer ears to check for excessive amounts of cerumen.
D) Watch to see if the infant reacts when the nurse's hands are clapped together.

Answer 1

Watch to see if the infant reacts when the nurse's hands are clapped together.

Question 2

Which nursing diagnosis is most appropriate for a patient with xerostomia?

A) Total urinary incontinence related to inability to feel urge to urinate
B) Bathing self-care deficit related to inability to perceive left-sided body parts
C) Impaired oral mucus membranes related to decreased salivation and dry mouth
D) Disturbed sensory perception related to feeling of electric pain in feet and hands

Answer 2

Impaired oral mucus membranes related to decreased salivation and dry mouth

Question 3

Which assessment finding indicates that the patient has developed diabetes-induced peripheral neuropathy?

A) The nurse must speak louder than usual to be understood by the patient.
B) Fine tremors of the hands that worsen when the patient tries to eat or write.
C) Painful muscle spasms with hyperreactive Achilles and quadriceps reflexes.
D) No pain is felt when the patient's feet are burned after walking on hot pavement.

Answer 3

No pain is felt when the patient's feet are burned after walking on hot pavement.

Question 4

Which is the most appropriate goal for a patient with the nursing diagnosis risk for loneliness related to loss of spouse and admission to long-term nursing facility?

A) The patient will use effective coping strategies to prevent self-harm.
B) The patient will participate in at least one group activity every week.
C) The patient will assist staff with activities of daily living every morning.
D) The patient will express the desire to achieve increased levels of comfort.

Question 5

Which complication may develop as a result of frequent middle ear infections as a child?

A) Meniere's disease
B) Serous otitis media
C) Hearing impairment
D) Impaction of cerumen

Question 6

The nurse is caring for a patient who becomes agitated when visitors stay for extended periods or the hospital unit becomes noisy.The nurse identifies this as sensory overload.Which interventions will be of benefit to the patient?

A) Reduce the number of visitors to the patient's room.
B) Provide a dedicated period of rest time each afternoon.
C) Institute a unit-wide quiet time at 10:00 p.m.each night.
D) Turn on the television to drown out noise from other patients.
E) Coordinate therapies and tests with other departments and providers.

Question 7

Which assessment finding indicates to the nurse that the patient is experiencing difficulty with proprioception?

A) The patient must hold on to the railing when ambulating in the hallway.
B) The patient must add extra seasoning to food in order for it to have any flavor.
C) The patient did not smell smoke even though the smoke detector was alarming.
D) The patient suffered a first-degree burn when a heating pad was left on too long.

Question 8

Which medications can lead to development of tinnitus?

A) Furosemide
B) Vancomycin
C) Insulin glulisine
D) Docusate sodium
E) Naproxen sodium

Question 9

A nurse is caring for a patient who signs and lip reads.When communicating,the most appropriate nursing action is to do which of the following?

A) Rely on friends or family members to interpret for the patient.
B) Sit facing the patient when speaking and ensure there is adequate light.
C) Repeat the entire conversation if it is not clearly understood the first time.
D) Speak louder and more distinctly than normal with exaggerated lip movements.

Question 10

The parent is concerned because the child has been referred to an optometrist after a routine eye screening at school.What is the nurse's most appropriate response to the parent?

A) "Most children have a mild form of color blindness as their eyes mature."
B) "You should wash the child's eyelids every morning with a damp washcloth."
C) "It is normal for children to squint to see but it should be checked out anyway."
D) "Most likely your child will need glasses to see the teacher and board at school."

Question 11

Which is the priority nursing diagnosis for a patient who has been diagnosed with Meniere's disease?

A) Nausea related to constant sensation of noxious taste
B) Acute confusion related to delirium and disorientation
C) Risk for falls related to unsteadiness and loss of balance
D) Autonomic dysreflexia related to distention of bowel or bladder

Question 12

The nurse is caring for a patient with the nursing diagnosis of disturbed sensory perception related to loud,bright hospital environment.Which is the priority intervention for the patient's care plan?

A) Maintain eye contact with the patient and avoid chewing gum.
B) Ask the patient to repeat information back to ensure understanding.
C) Repeatedly orient the patient to time,place,and the hospital room surroundings.
D) Shut the patient's door and avoid turning on the bright overhead lights in the room.

Question 13

Which activity should be avoided by older adults due to age-related vision changes?

A) Driving after dark
B) Digital photography
C) Typing on the computer
D) Doing crossword puzzles

Question 14

Which term will the nurse use to document the patient's age-related hearing loss?

A) Tinnitus
B) Meniere's disease
C) Presbycusis
D) Presbyopia

Question 15

A patient has had no visitors during a lengthy hospitalization.The patient is bored,restless,and irritable.Which term best describes the patient's feelings?

A) Sensory deficits
B) Sensory overload
C) Sensory deprivation
D) Changes in attitudes

Question 16

Although the patient can see movement in the periphery,the patient can no longer see to read books or do crossword puzzles.Which is the most likely cause of the patient's vision loss?

A) Cataracts
B) Glaucoma
C) Diabetic retinopathy
D) Macular degeneration

Question 17

The nurse is caring for a patient who has a severe right-sided stroke with left-sided hemiplegia.The patient uses the right extremities well but does not realize that the left arm and leg even exist.Which is the most appropriate nursing diagnosis for this patient?

A) Deficient knowledge related to presence of paralyzed left arm and leg
B) Unilateral neglect related to brain tissue damage after right-sided stroke
C) Ineffective denial related to inability to accept paralysis of left arm and leg
D) Noncompliance related to inability to follow directions to use left arm and leg

Question 18

Which nursing intervention is the highest priority when caring for an impulsive,forgetful stroke patient with right-sided paralysis?

A) Complete a fall risk assessment such as the Hendrich II Fall Risk Model.
B) Utilize a bed alarm and respond immediately when it is triggered.
C) Place the call light within easy reach and remind the patient to use it.
D) Apply a soft restraint to the patient's left wrist to prevent getting out of bed.

Question 19

The patient tells the nurse that it is much easier to read books on the tablet computer after applying a matte screen protector.Which is the best explanation for this?

A) Glare causes headaches.
B) Glare reduces visual acuity.
C) Bright light overstimulates the retina.
D) Too much light damages the iris.

Question 20

Which assessment findings put the patient at high risk for development of vision problems?

A) Takes insulin glulisine for type 1 diabetes.
B) Takes metoprolol to treat hypertension.
C) Takes docusate sodium for constipation.
D) Takes acetaminophen for osteoarthritis pain.
E) Takes prednisone for multiple sclerosis.