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NursingFundamentals NursingFundamentals of NursingPractice Set 9
NursingFundamentals NursingFundamentals of NursingPractice Set 9Sensory Alterations
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Question 1
Free
Multiple Choice
A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" How will the nurse interpret the finding when the child said that it was sharp?
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The child's sensation is intact.
The child's reception is intact.
The child's perception is intact.
The child's reaction is intact.
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Question 2
Free
Multiple Choice
A nurse is caring for a patient with presbycusis. Which assessment finding indicates an adaptation to the sensory deficit?
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The patient frequently cleans out eyes with saline washes.
The patient applies different spices during mealtime to food.
The patient turns one ear toward the nurse during conversation.
The patient isolates self from social situations with groups of people.
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Question 3
Free
Multiple Choice
The nurse will be most concerned about the risk of malnutrition for a patient with which sensory deficit?
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Xerostomia
Dysequilibrium
Diabetic retinopathy
Peripheral neuropathy
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Question 4
Free
Multiple Choice
A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?
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Impaired night vision
Difficulty hearing low pitch
Heightened sense of smell
Increased taste discrimination
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Question 5
Free
Multiple Choice
A nurse is caring for an older-adult patient who was in a motor vehicle accident because the patient thought the stoplight was green. The patient asks the nurse "Should Istop driving?" Which response by the nurse is most therapeutic?
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"Yes, you should stop driving. As you age, your cognitive function declines, and becoming confused puts everyone else on the road at risk."
"Yes, you should ask family members to drive you around from now on. Your reflex skills have declined so much you can't avoid an accident."
"No, as you age, you lose the ability to see colors. You need to think about stoplights in a new way. If the top is lit up, it means stop, and if the bottom is lit up, it means go."
"No, instead you should see your ophthalmologist and get some glasses to help you see better."
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Question 6
Multiple Choice
A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient's plan of care?
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Teach the patient about special assistive devices.
Make the patient talk as much as possible.
Obtain an order for antidepressant medications.
Place a consult for a home health nurse.
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Question 7
Multiple Choice
A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan?
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Risk for falls
Self-care deficit
Social isolation
Impaired physical mobility
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Question 8
Multiple Choice
During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further?
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Neurological deficit
Visual deficit
Hearing deficit
Balance deficit
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Question 9
Multiple Choice
A home health nurse is assembling a puzzle with an older-adult patient and notices that the patient is having difficulty connecting two puzzle pieces. Which aspect of sensory deprivation will the nurse document as being most affected?
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Perceptual
Cognitive
Affective
Social
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Question 10
Multiple Choice
Which assessment question should the nurse ask to best understand how visual alterations are affecting the patient's self-care ability?
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"Have you stopped reading books or switched to books on audiotape?"
"What do you do to protect yourself from injury at work?"
"Are you able to prepare a meal or write a check?"
"How does your vision impairment make you feel?"
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Question 11
Multiple Choice
A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?
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Administer a Mini-Mental State Examination (MMSE).
Ask the patient to state name, location, and what month it is.
Ask the patient's family if the patient is behaving normally.
Administer the hearing handicap inventory for the elderly (HHIE-S).
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Question 12
Multiple Choice
The nurse is using the Snellen chart. Which patient is the nurse assessing?
Choose correct answer/s
A patient who frequently reports the incorrect time from the clock across the room.
A patient who is having difficulty remembering how to perform familiar tasks.
A patient who turns the television up as loud as possible.
A patient who has trouble saying words.
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Question 13
Multiple Choice
A new nurse is caring for a patient who is undergoing chemotherapy for cancer. The patient is becoming malnourished because nothing tastes good. Which recommendation by the nurse will be most appropriate for this patient?
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"Rinse your mouth several times a day to hydrate your taste buds."
"Avoid adding spices or lemon juice to food to prevent nausea."
"Blend foods together in interesting flavor combinations."
"Eat soft foods that are easy to chew and swallow."
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Question 14
Multiple Choice
The nurse is creating a plan of care for a patient with glaucoma. Which nursing diagnosis will the nurse include in the care plan to address a safety complication of the sensory deficit?
Choose correct answer/s
Body image disturbance
Social isolation
Risk for falls
Fear
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Question 15
Multiple Choice
The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift?
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Expressive
Receptive
Global
Motor
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Question 16
Multiple Choice
The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?
Choose correct answer/s
Speaking with hands, face, and expressions
Using a loud voice, enunciating every syllable
Having direct conversation with the patient in the affected ear
Repeating the phrase again, if the patient does not understand what the nurse said
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Question 17
Multiple Choice
The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning?
Choose correct answer/s
Asks the nurse to test the temperature of the water before entering the bath.
Places colored stickers on faucet handles to indicate temperature.
Replaces all lace-up shoes with Velcro straps for ease.
Uses a heating pad on a low setting to keep warm.
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Question 18
Multiple Choice
A nurse is working to prevent blindness. Which preventive action is a priority?
Choose correct answer/s
Screen young adults early for visual impairments.
Include rubella and syphilis screening in the preconception care plan.
Instruct parents to report reduced eye contact from their child immediately.
Administer eye prophylactic antibiotics to newborns within 24 hours after birth.
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Question 19
Multiple Choice
The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient?
Choose correct answer/s
Administer an opioid medication to help the patient sleep.
Keep the door open during the night.
Open the shades at night.
Provide the patient with earplugs.
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Question 20
Multiple Choice
The nurse is caring for a patient with expressive aphasia from a traumatic brain injury. Which goal will the nurse include in the plan of care?
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Patient will carry a pen and a pad of paper around for communication.
Patient will recover full use of speech vocabulary in 1 day.
Patient will thicken drinks to prevent aspiration.
Patient will communicate nonverbally.
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