Deck 18: Sensory Function

Question 1

An 88-year-old patient 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 diagnosed with Ménière disease is prescribed meclizine and hydrochlorothiazide.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 2

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

Question 3

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

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

Answer 3

Use of prescription medications

Question 4

A 77-year-old patient has impacted cerumen.During the nursing assessment,the nurse confirms supporting evidence of the condition when noting

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

Question 5

A patient had cataract surgery without a lens implant.What teaching point is most important?

A)Keep your follow-up appointment with the surgeon.
B)Instill your eyedrops just like we have practiced.
C)Do not drive and be careful going up or down stairs.
D)Take acetaminophen if needed for pain.

Question 6

Which of the following are appropriate steps to take when removing cerumen from an older person's ear? (Select all that apply. )

A)Instill a softening agent first.
B)Use hot water and hydrogen peroxide.
C)Use an ear syringe and warm water for irrigation
D)Have the patient lean backward to drain the water.
E)Have the patient lean forward toward the affected side to drain the water.

Question 7

A 66-year-old patient has been diagnosed with type 2 diabetes mellitus and related vision loss.Which statement demonstrates the ability to manage her condition?

A)"I schedule my yearly eye examination for the week of my birthday."
B)"When I notice haloes around lights,I'll know I have 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 8

An older adult's chart documents that she has been diagnosed with macular disequilibrium.Based on an understanding of this condition the nurse suggests that the patient

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 96-year-old patient reports symptoms of xerostomia.What action by the nurse will be most helpful in minimizing the effects of this condition?

A)Providing appropriate fluids with the patient's meals
B)Cutting the patient's meat into small bite-sized pieces
C)Elevating the head of the patient's bed at mealtimes
D)Assisting the patient with oral care before each meal

Question 10

A nurse is assessing a patient who reports moderate tinnitus.The nurse should assess the patient for which of the following? (Select all that apply. )

A)Alcohol and caffeine intake
B)Unilateral or bilateral symptoms
C)Cerumen impaction
D)Frequent ear infections
E)Exposure to radiation

Question 11

An older adult patient reports burning and itching eyes.On assessment,the nurse notes swelling of the eyelid margins bilaterally.What additional data would the nurse assess for?

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

Question 12

A patient with glaucoma is on timolol.The patient also takes metoprolol for hypertension.The patient reports to the clinic nurse that the eyedrops "Make me dizzy." What assessment by the nurse is most appropriate?

A)Assess the patient's eyedrop instillation technique.
B)Determine how long the patient has been on the drops.
C)Assess the patient's gait and balance while walking.
D)Ask the patient if breakfast is eaten prior to applying the eyedrops.

Question 13

An older patient 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 patient about the function of hearing aids?

A)Hearing aids amplify sound but do not improve the ability to hear.
B)Hearing aids improve hearing 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.

Question 14

A patient in a nursing home is confused,nonverbal,but pleasant.The nurse notes the patient has suddenly become agitated and is screaming and scratching at the eyes.While the nurse is examining the patient,the patient vomits.What action by the nurse is best?

A)Consult the provider about an ophthalmologic exam.
B)Sedate the patient so she won't injure herself.
C)Place mitts on the patient's hands to avoid scratches.
D)Give the patient a prn medication for pain.

Question 15

A patient had a chemical splash into the eye at work.What action by the occupational health nurse takes priority?

A)Begin flushing the patient's eye with cool water.
B)Call emergency medical services.
C)Ask about the patient's tetanus status.
D)Tape the eye closed to prevent injury.

Question 16

A patient has Meniere disease.What statement by the patient indicates a good ability to manage the condition?

A)"Because it's from dehydration,I can increase salt in my food."
B)"There are no medications,so I just have to learn to live with it."
C)"If I get dizzy I should lie down immediately and hold my head still."
D)"Because I have asthma,I cannot take any medications for Meniere disease."

Question 17

The morning of her scheduled cataract extraction and intraocular lens placement of the right eye,an older adult patient expresses concern that she will not remember her instructions for home care.Which statement is the best response to the patient'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 reinforce the important points."
D)"We will provide you with written instructions."

Question 18

When assessing the patient'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 19

A patient has been admitted to the post anesthesia care unit after a trabeculectomy.What assessment takes priority?

A)Airway
B)Pain
C)Eye patch
D)Blood pressure

Question 20

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

A)speak loudly into the patient'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.