Question 1

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

Accepted Answer

Neonates without hearing impairments respond to loud noises.Atrophy of the cerumen glands,seen mainly in older adults,cause thicker and dryer wax,which is more difficult to remove and may completely obstruct the auditory canal.Hearing loss can be determined at any age with additional testing by an ENT specialist.Using an otoscope,reviewing the medication list,and examining the infant's outer ears will not assess for hearing loss.

Question 2

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

Accepted Answer

Xerostomia is a decrease in salivary production leading to dry mouth.This can cause damage to oral mucus membranes.Xerostomia does not include urinary disturbances or neuropathic pain.

Question 3

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

Accepted Answer

Diabetic peripheral neuropathy may present with pain or loss of sensation in the extremities,particularly the feet.The patient who does not feel pain when the feet are burned is experiencing peripheral neuropathy.Diabetic peripheral neuropathy does not affect hearing or cause tremors or muscle spasms.

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?

Accepted Answer

The appropriate goal for a patient at risk of loneliness is for the patient to participate in at least one group activity every week.This will allow the patient to meet other residents and hopefully develop some friendships.The prevention of self-harm,assisting with activities of daily living,and desiring increased comfort are not appropriate goals for risk of loneliness.

Question 5

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

Accepted Answer

Hearing impairment is common in the United States.At-risk children include those with a family history of childhood hearing impairment,perinatal infection (rubella,herpes,or cytomegalovirus),low birth weight,chronic ear infections,and Down syndrome.Frequent middle ear infections do not lead to impaction of cerumen or Meniere's disease.Serous otitis media is another name for a middle ear infection.

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?

Accepted Answer

Reduce sensory overload by organizing the patient's care to control for excessive stimuli.Reducing the number of visitors to the patient's room and instituting a unit-wide quiet time can help the patient to rest comfortably.Coordination with other departments will reduce the time needed for therapies and tests.

Question 7

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

Accepted Answer

Proprioception is the patient's ability to balance and maintain position.The patient's proprioception is affected when the patient is unable to ambulate without holding on to the handrail.Proprioception does not affect taste,smell,or sensation.

Question 8

Which medications can lead to development of tinnitus?

Accepted Answer

Ototoxic medications,such as analgesics,antibiotics (such as vancomycin and aminoglycosides),or diuretics,affect hearing acuity,balance,or both,with the most common symptom being tinnitus (ringing in the ears).Surgical anesthesia,morphine,and docusate sodium do not have the side effect of ototoxicity or tinnitus.

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?

Accepted Answer

Nurses can use a variety of communication techniques,including reading notes and writing notes,as well as reading lips and signing.When communicating,nurses should speak slowly and articulate clearly.The nurse should be seated facing the patient and ensure that there is enough light for the patient to see the nurse's lips clearly.When you are not understood,rephrase rather than repeating the entire conversation.Some patients with hearing impairments are able to speak normally.To more clearly hear what a person communicates,family and friends need to learn to move away from background noise,rephrase rather than repeat sentences,be positive,and have patience.On the other hand,some deaf patients have serious speech alterations.

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?

Accepted Answer

The most common visual problem during childhood is a refractive error such as nearsightedness.The parent can be told that the child may likely require glasses in order to see clearly over far distances.Color blindness is not common in childhood and only affects males.Squinting is not normal at any age.Washing the child's eyelids every morning will not affect the child's need for corrective lenses.

Question 11

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

Accepted Answer

Meniere's disease causes vertigo,a sensation of the environment spinning.This causes the patient to be unsteady and at high risk for falls.Nausea is less of a priority than falls.Meniere's disease does not cause confusion or autonomic dysreflexia.

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?

Accepted Answer

The nurse should try to reduce the patient's sensory overload by closing the patient's door and avoiding the use of bright overhead lights.Dimmer reading lights should be used whenever possible.Maintaining eye contact,having the patient repeat information,and orienting the patient to the surroundings will not reduce the sensory overload of the bright,loud hospital environment.

Question 13

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

Accepted Answer

Visual changes often include reduced visual fields,increased glare sensitivity,impaired night vision,reduced accommodation,reduced depth perception,and reduced color discrimination.Many of these symptoms occur because the pupils in the older adult take longer to dilate and constrict secondary to weaker iris muscles.For this reason the older adult should be encouraged to avoid driving after dark.Reading glasses are often required for typing and writing.Digital photography is not affected by age-related vision changes.

Question 14

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

Accepted Answer

Hearing changes often associated with aging include decreased hearing acuity,speech intelligibility,and pitch discrimination,which is referred to as presbycusis.Low-pitched sounds are easiest to hear,but it is difficult to hear conversation over background noise.A decrease in active sebaceous glands causes the cerumen to become dry and completely obstruct the external auditory canal.Tinnitus is commonly caused by ototoxicity and patients experience the sensation of ringing in the ears.Presbyopia refers to the gradual decline in ability of the lens to accommodate or focus on close objects and reduces ability to see near objects clearly.Although the cause of Meniere's disease is unknown,the symptoms include progressive low-frequency hearing loss,vertigo,tinnitus,and a full feeling or pressure in the affected ear.

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?

Accepted Answer

Sensory deprivation occurs when inadequate quality or quantity of stimuli impairs a patient's perception.It can cause affective changes (e.g.,boredom,restlessness,increased anxiety,emotional lability)and/or perceptual changes (e.g.,reduced attention span,disorganized visual and motor coordination,confusion of sleeping and waking states).Sensory deficits such as low vision and blindness are very common forms of disability.When a person receives multiple sensory stimuli,the brain has difficulty distinguishing the stimuli,leading to sensory overload.A person with sensory overload no longer perceives the environment in a way that makes sense.Sensory deprivation can be caused from living in a nonstimulating environment.Ask the patient how to improve the quality of stimulation in the environment.

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?

Accepted Answer

Age-related macular degeneration occurs when the macula (specialized portion of the retina responsible for central vision)degenerates as a result of aging and loses its ability to function efficiently.An early sign includes distortion that causes edges or lines to appear wavy.In later stages,patients may see dark or empty spaces that block the center of vision.Cataract is clouding of the lens in the eye that affects vision.Interferes with passage of light through the lens and reduces the light that reaches the retina.Cataracts usually develop gradually and often result in cloudy or blurry vision,glare,double vision,and poor night vision.Glaucoma is a slowly progressive increase in intraocular pressure that causes progressive pressure against the optic nerve.At first,vision stays normal,and there is no pain.If left untreated,there may be a loss of peripheral (side vision).Diabetic retinopathy are pathological changes of the blood vessels of the retina secondary to increased pressure resulting in hemorrhage,macular edema,and reduced vision or vision loss.

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?

Accepted Answer

Unilateral neglect occurs when the patient is unaware that a body area exists after a neurological injury or stroke.This patient demonstrates unilateral neglect by not realizing that the left arm and leg exist.Knowledge deficit,noncompliance,and ineffective denial do not explain the patient's lack of realization of the left-sided extremities.

Question 18

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

Accepted Answer

The nurse should utilize a bed alarm for the patient and respond immediately when it is triggered indicating that the patient is starting to get up.This way the nurse will be able to intervene before the patient is able to get out of the bed.The patient is already known to be a fall risk so completing an additional fall risk assessment is unnecessary.The patient is forgetful and likely will not remember to use the call light.Restraints should be used only as a last result as they can cause significant injury and distress to the patient.

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?

Accepted Answer

When a patient ages,the pupil loses the ability to adjust to bright light.An antiglare screen protector therefore makes it easier for the patient to read text on the tablet computer.While glare can cause headaches for some people,it does not explain why the patient has an easier time reading text on the computer after the antiglare screen protector is applied.Overly bright light does not cause overstimulation of the retina or damage to the iris.

Question 20

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

Accepted Answer

History of diabetes and hypertension are both significant risk factors for eye diseases such as glaucoma and retinopathy.Prednisone is associated with early development of cataracts.Constipation,osteoarthritis,acetaminophen,and docusate sodium do not put the patient at high risk for vision problems.

Quiz 39: Sensory Alterations