Deck 18: Sensory Perception

Question 1

The nurse is providing instruction to the parents of a 7-month-old infant who has just been diagnosed with hearing loss.What guidance should the nurse provide?

A) Hearing loss is not serious until 1 year of age.
B) Interventions to support hearing are not useful until the child is at least 9 months old.
C) Expect that your child will be enrolled in a special hearing intervention program immediately.
D) Keep your child in a quiet environment until additional testing is done.

Answer 1

Expect that your child will be enrolled in a special hearing intervention program immediately.

Question 2

The nurse is planning care for a client with an uncorrectable hearing loss.Which strategies for communication should the nurse add to the client's plan of care? Select all that apply.

A) Magic slate
B) Total communication
C) Hearing aids
D) Cued speech
E) Sign language

Answer 2

Total communication
Cued speech
Sign language

Question 3

The nurse identifies potential safety concerns for a client with a sensory disorder.Which intervention should the nurse include in this client's plan of care?

A) Teach how to adapt to the sensory deficit.
B) Identify assistive devices.
C) Provide meaningful interaction and stimulation.
D) Teach the need to take antibiotics as prescribed.

Answer 3

Identify assistive devices.

Question 4

A client tells the nurse about plans to become pregnant.What should the nurse provide to ensure healthy sensory functioning of the newborn?

A) Testing for rubella
B) The need to limit vitamin A intake
C) Importance of ingesting zinc
D) Avoiding foods high in folic acid

Question 5

A client is recovering from cochlear implant surgery.What is true regarding cochlear implants?

A) They restore normal hearing to those who could not hear any sound prior to implantation.
B) Their function is more similar to the way the ear normally receives and processes sounds than it is to that of a hearing aid.
C) They may be the only hope for restoring sound perception for the client with a total and permanent hearing loss.
D) With implantation, the structures of the middle ear are reconstructed to improve conductive hearing deficits.

Question 6

An older adult client,reporting a significant loss of hearing after being involved in an explosion,asks when hearing will return.Which response by the nurse is most appropriate?

A) Surgery will help restore the hearing you have lost.
B) The most common cause of hearing impairments is exposure to loud noises.
C) Loud noises can cause immediate, permanent loss of hearing.
D) Hearing loss attributed to loud noises is normally reversible.

Question 7

The nurse is evaluating the care received by a client who has a hearing deficit.Which client statement indicates that care has been effective?

A) "I ask others to face me when they talk, as I can hear them better."
B) "I hear better when the television volume is raised."
C) "I will change the battery in my hearing aid once a month."
D) "I might use the hearing aid when I go shopping."

Question 8

A client recovering from surgery to repair fractured bones in the face tells the nurse that dinner "tastes horrible." Which response by the nurse is most appropriate?

A) "The meal on your tray is the best the cafeteria has to offer today."
B) "Let me see if I can order something else for you from the cafeteria."
C) "You do not have to eat anything you don't want to."
D) "The facial injuries are affecting your sense of taste and flavor."

Question 9

The nurse is providing care to a client with a hearing deficit.Which intervention should the nurse use when providing care to this client?

A) Overarticulate words.
B) Vary the volume of voice through sentences.
C) Face the client during conversation.
D) Use short phrases.

Question 10

A nurse is caring for a client who is receiving IV tobramycin for the treatment of a respiratory infection.On which sensory factor will the nurse focus when concerned about this medication's toxic effects on the body?

A) Taste
B) Hearing
C) Vision
D) Swallowing

Question 11

A client with impaired hearing is scheduled for a test to measure the compliance of the middle ear to sound transmission.Which diagnostic test will the nurse include in the client's education?

A) Tympanometry
B) Weber test
C) Rinne test
D) Whisper test

Question 12

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 a priority for this client?

A) Imbalanced Nutrition: Less than Body Requirements
B) Disturbed Sleep Pattern
C) Risk for Injury
D) Disturbed Sensory Perception: Auditory

Question 13

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

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

Question 14

The nurse has identified the diagnosis Disturbed Sensory Perception: Auditory for a client.Which intervention would be the most appropriate for this client?

A) Replace batteries in hearing aids every week.
B) Use facial expressions or gestures when talking.
C) Face the client when speaking.
D) Use a low voice pitch with normal loudness when talking.

Question 15

A client with glaucoma is experiencing sensory overload.What can the nurse suggest to reduce this client's visual overstimulation?

A) Do not go outside during the daytime.
B) Wear sunglasses that block UVA and UVB rays.
C) Insert artificial tears several times a day.
D) Use an over-the-counter eye drop for irritation.

Question 16

The nurse suspects that a client has a hearing disorder; however,the client denies not being able to hear.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 17

The nurse is preparing a seminar for community members on actions to protect sensory functioning when aging.What should the nurse recommend regarding hearing tests for older adults?

A) Schedule an annual hearing test until the age of 50 and then have a test every 6 months.
B) A hearing test is needed when changing medications.
C) A hearing test should be done biannually after the age of 60.
D) Have a hearing test every 10 years until age 50 and then every 3 years.

Question 18

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

A) Overarticulating words 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 19

A client tells the nurse about having increasing difficulty seeing the print while reading a newspaper.Which tool will the nurse use when assessing this client?

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

Question 20

A nurse is caring for a client with a genetic nerve disorder who has a deficit when attempting to move the tongue.When assessing this client,the nurse expects a deficit with which cranial nerve?

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

Question 21

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,which conclusion by the nurse is appropriate?

A) A deterioration in vision
B) The need for artificial tears
C) An improvement in vision
D) An indication of poor nutrition

Question 22

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) Wear eye goggles when playing outdoors at all times.
B) Keep household products within easy reach.
C) Supervise when lighting fireworks.
D) Keep sharp objects out of reach of young children.

Question 23

The nurse provides postoperative teaching to a client recovering from cataract removal surgery.Which client statement indicates that preoperative teaching has been effective?

A) "I will be hospitalized for several days recovering from this surgery."
B) "I will need to return to activity as soon as possible."
C) "I will use the eye drops if I have eye pain"
D) "I will notify the doctor if I have itching or redness of the eye after the surgery."

Question 24

A client asks the nurse how glaucoma develops.Which response by the nurse is appropriate?

A) "Blue eyes are a risk factor in the development of glaucoma."
B) "Heart disease is a risk factor in the development of glaucoma."
C) "People with arthritis develop glaucoma most often."
D) "When the pressure in the eye is high enough to cause optic nerve damage, glaucoma can develop."

Question 25

A client who is a firefighter sustains an eye injury caused by falling debris while cleaning up after a house fire.The client asks what can be done to prevent eye injuries in the future.What should the nurse instruct the client?

A) Irrigate the eyes with water after putting out a fire.
B) Wear protective glasses or goggles.
C) Use artificial tears every day.
D) Apply warm soaks to the eyes every evening before sleep.

Question 26

The mother of a premature newborn asks the nurse why the baby's eyes are cloudy.Which response by the nurse is appropriate?

A) "It is because of an allergic reaction."
B) "It happens with most newborns."
C) "It is because you developed an illness while carrying the baby before birth."
D) "It is seen with premature infants."

Question 27

A client comes into the emergency department with an eye injury after being hit with a tennis ball.Which assessment findings does the nurse anticipate? Select all that apply.

A) Lid ecchymosis with subconjunctival hemorrhage
B) Decreased visual acuity and a reddish tint to vision
C) Photophobia and eye tearing
D) Cloudy cornea
E) Eye pain and loss of vision

Question 28

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 appropriate?

A) "Only your doctor can tell if you have a cataract in your left eye."
B) "Cataracts develop at different rates, so one eye will be more affected than the other."
C) "Don't worry about it until you can't see out of your left eye."
D) "Your doctor must have made an error."

Question 29

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 Sensory Perception: Visual
B) Decisional Conflict
C) Risk for Ineffective Health Maintenance
D) Ineffective Coping

Question 30

A nurse is caring for a client who is postoperative from cataracts surgery.For which eye injury is this client most at risk following cataracts surgery?

A) Blunt trauma
B) Retinal detachment
C) Perforating injury
D) Penetrating injury

Question 31

After the removal of a foreign body from the eye,a client is diagnosed with a corneal abrasion.Which will be indicated in the care of this client?

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

Question 32

After conducting a physical assessment,the nurse determines that the client is at risk for developing cataract.Which item in the health history support that the client is at risk for developing cataracts?

A) Age 75 years
B) Hypertension
C) Minimal direct sun exposure
D) Nonsmoker

Question 33

An older adult client prescribed eye drops as treatment for glaucoma is experiencing a change in eye color after using the medication.When the client asks why this is occurring,which response by the nurse is appropriate?

A) "This is an expected side effect of the medication."
B) "What do you mean that your eyes have changed color?"
C) "This is unusual; please come in for an evaluation."
D) "Are you sure that your eyes have changed color?"

Question 34

The nurse is caring for a client recovering from surgery to repair a detached retina.In which position should the client be placed?

A) Prone
B) Flat
C) Semi-Fowler on the affected side
D) Semi-Fowler on the unaffected side

Question 35

The nurse is caring for a client with a penetrating eye injury.Which action is appropriate for the nurse to include in the plan of care?

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

Question 36

A nurse working in the emergency department is caring for a client with an eye injury.Which assessment finding would support the diagnosis of a retinal detachment?

A) Reddened area in conjunctiva
B) "Floaters" noted in field of vision
C) Possible bleeding or extrusion of eye contents
D) Red, edematous conjunctiva

Question 37

The nurse is planning care for a client scheduled for cataract surgery.Which interventions should the nurse include in the client's plan of care? Select all that apply.

A) Instruct on the administration of eye drops.
B) Wear sunglasses if necessary.
C) Avoid strenuous activity until seen by the ophthalmologist after the surgery.
D) Resume normal activities of daily living after the procedure.
E) Limit food and fluids until fully recovered from anesthesia.

Question 38

The nurse is reviewing discharge instructions with a client who had outpatient surgery for cataract removal.What should these instructions include?

A) Phone the healthcare provider with any signs of eye drainage.
B) Do not bend to pick up objects.
C) Healing will be complete in 2 weeks.
D) Wear the eye patch the day of surgery only.

Question 39

A client has been diagnosed with cataracts of both eyes.Which prescription does the nurse anticipate for this client?

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

Question 40

A client diagnosed with open-angle glaucoma asks the nurse what that means.Which response by the nurse is appropriate?

A) "It is a rare type of glaucoma."
B) "One of the first signs of it is pain behind the eyes."
C) "It means that the condition occurs within days."
D) "The eye cannot drain the fluid that it produces."

Question 41

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) Expect eye pain with the condition.
B) Explanation of how permanent blindness will not occur
C) Method to self-administer prescribed eye medication
D) Importance of attending follow-up appointments with the physician
E) Avoiding over-the-counter medication unless discussed with the physician

Question 42

A nurse is caring for a client with glaucoma who is prescribed a topical beta-adrenergic blocking agent.When teaching this client about the medication,which will the nurse include?

A) Relaxes the ciliary muscle, improving the outflow of aqueous humor and reducing intraocular pressure.
B) May cause blurred vision and stinging.
C) When used long term, causes permanent darkening of the iris of the eye and eyebrows.
D) Reduces intraocular pressure by decreasing the production of aqueous humor in the ciliary body.

Question 43

A client with a long history of type 2 diabetes mellitus complains of occasional cold and numb hands and feet.Based on this data,which diagnosis does the nurse anticipate?

A) High blood glucose level
B) Low blood glucose level
C) Peripheral neuropathy
D) Pancreatitis

Question 44

During an assessment,the nurse learns that a client is experiencing numbness and tingling of the feet and hands.Which findings could be contributing to this client's symptoms? Select all that apply.

A) Works on the weekends as an automobile mechanic.
B) Plays tennis every Saturday.
C) Alcohol intake one six-pack of beer per day
D) Diagnosed with hypothyroidism
E) Employed as a computer operator

Question 45

A nurse is educating a client with glaucoma about the different types of the disease.Which statement is appropriate for the nurse to include in the teaching session?

A) "Angle-closure glaucoma is the most common form of glaucoma among adults."
B) "Open-angle glaucoma usually affects only one eye at a time."
C) "Open-angle glaucoma occurs more frequently in Latinos and African-Americans."
D) "Episodes of angle-closure glaucoma usually affect both eyes at a time."

Question 46

During an assessment,the nurse determines that the client at risk for the development of macular degeneration.Which did the nurse find in the client's health history?

A) Fibromyalgia
B) Smoking
C) Arthritis
D) Acid reflux disease

Question 47

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

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

Question 48

A client is receiving verteporfin treatment for macular degeneration.Which instruction by the nurse is appropriate based on this data?

A) Use artificial tears to keep the eyes moist.
B) Do not lift heavy objects for 2 weeks after the treatment.
C) Flush the eyes with warm water twice a day.
D) Avoid sunlight or bright indoor light for 5 days after treatment.

Question 49

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) Floaters
C) Vision changes from a stroke
D) Macular degeneration

Question 50

The nurse is planning the care for a client with peripheral neuropathy.Which interventions would assist with disturbed sensory perception? Select all that apply.

A) Frequent rest periods
B) Smoking cessation
C) Frequency of pain medication
D) Relaxation techniques
E) Nutrition

Question 51

A client with glaucoma has been using timolol (Timoptic)to manage the condition for the past 3 years.Which assessment finding indicate the client is experiencing an adverse reaction to the medication?

A) Excessive salivation
B) Heart rate less than 57 beats per minute
C) Reduced urinary output
D) Diarrhea

Question 52

A client is prescribed a beta blocker as treatment for glaucoma.What should the nurse instruct this client about this medication?

A) Occlude the lacrimal duct after administration.
B) Expect the fingers and toes to tingle.
C) Measure weight daily.
D) Expect to have eye pain.

Question 53

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) Disturbed Sensory Perception
C) Ineffective Coping
D) Pain

Question 54

The nurse is preparing discharge instructions for a client with macular degeneration 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 at home
D) Information on Medic-Alert bracelets

Question 55

An older adult client with macular degeneration tells the nurse that "all of a sudden" the television screen appeared distorted,with the colors all "wrong." Which action by the nurse is appropriate?

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 bed rails.
D) Contact the healthcare provider for an immediate ophthalmological evaluation.

Question 56

The nurse identifies that a client with macular degeneration is experiencing disturbed sensory perception.What interventions should the nurse plan for this client? Select all that apply.

A) Maintain on bed rest.
B) Instruct on increasing fruits and vegetables in the diet.
C) Provide information learning how to read Braille.
D) Provide large-print reading materials.
E) Restrict fluids.

Question 57

The nurse has identified the nursing diagnosis Disturbed Sensory Perception: Visual as appropriate for a client with glaucoma.Which intervention should be added to this client's plan of care?

A) Keep bed rails in the low position.
B) Assess coping mechanisms.
C) Turn off lights when leaving the client's room.
D) Provide assistance with meals and eating.

Question 58

A client with macular degeneration tells the nurse that vision has improved after making dietary changes.What change did the client most likely implement?

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

Question 59

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

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

Question 60

The mother of an adolescent client diagnosed with Guillain-Barré syndrome asks the nurse why the client keeps asking for socks to be removed when the client is not wearing any socks.What should the nurse respond to the mother?

A) Confusion is a part of the disorder, and the client just thinks socks are on the feet.
B) There is a change in sensation, and the client feels like socks are being worn.
C) Medications are causing the client to feel like socks are being worn.
D) Tactile hallucinations are part of the disorder.

Question 61

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 62

A client tells the nurse about knowing when a vitamin B₁₂ injection is due because there is an increase in tingling of the fingers and toes.What does this information provide to the nurse?

A) The vitamin B₁₂ injections are helping the peripheral neuropathy.
B) The client believes the vitamin B₁₂ injections are helping the peripheral neuropathy.
C) The client does not like to take vitamins, and having a monthly injection is easier.
D) The client has poor nutrition, and the vitamin B₁₂ injections are needed.

Question 63

A client with peripheral neuropathy who is prescribed vitamin BB₁₂injections asks the nurse how this will help the numbness in his legs and feet.Which response by the nurse is appropriate?

A) "It will make you sleep better."
B) "It provides a supplement of a vitamin known to be low in people with numbness in their feet and legs."
C) "It will give you more energy to exercise."
D) "It will cause you to want to eat a better diet."