Nokea
A nurse is caring for a patient with a severe hearing deficit who reads lips and uses sign language. Which nursing intervention would best prevent sensory alterations for this patient?
- A. Turning the radio or television volume up very loud and closing the door to his room
- B. Preventing embarrassment and emotional discomfort as much as possible
- C. Providing daily opportunities for them to participate in a social hour with six to eight people
- D. Encouraging daily participation in exercise and physical activity
Correct Answer: C
Rationale: Providing opportunities for the patient to socialize builds on their strength of being able to lip-read and helps prevent sensory deprivation from hearing loss.
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A home care nurse is visiting an older adult with long-standing diabetes who reports pain and numbness in their feet. What education is most appropriate for this patient?
- A. Take acetaminophen or over-the-counter analgesic when pain occurs.
- B. Increase intake of foods containing vitamins B6, B12, and folate.
- C. Explain that phantom limb pain can become chronic, but psychosocial support can help.
- D. Validate the patient's understanding of foot care for patients with diabetes.
Correct Answer: D
Rationale: Patients with diabetes can develop peripheral neuropathy resulting in loss of sensation and reduced blood flow. The loss of sensation can promote injury the patient does not readily notice. Therefore, those with diabetes must perform special foot care and visual inspection.
During shift report, a nurse is told that their patient admitted with an electrolyte imbalance is experiencing delirium. For which finding consistent with delirium will the nurse assess?
- A. Statements that they plan to harm themselves or take their own life
- B. Chronic memory loss and personality changes
- C. Acute confusion, disorientation, restlessness, or agitation
- D. Ability to be aroused by extreme and/or repeated stimuli
Correct Answer: C
Rationale: Delirium is a state of acute confusion manifested by disorientation, restlessness, hallucinations, and agitation. Dementia is a chronic progressive illness characterized by difficulties with spatial orientation, memory, language, and changes in personality.
A nurse supervises APs in a long-term care facility where many residents have presbycusis. What directions will the nurse give the APs to best promote communication with these patients?
- A. Provide patients with large-print written menus.
- B. Speak clearly and distinctly, using a lower tone of voice.
- C. Decrease tactile stimulation.
- D. Remind all patients to "call, not fall."
Correct Answer: B
Rationale: Presbycusis is an expected decrease or loss of hearing as a result of the aging process. Speaking distinctly in lower frequencies is indicated. Obtaining large-print written material is appropriate for visual alterations. Decreasing tactile stimulation is appropriate for a patient with a sensory overload, and initiating a safety program to prevent falls is appropriate for a patient experiencing kinesthetic/visceral alterations.
Which of the following parameters must be in place to ensure a successful resolution of the reason for the Pirolla's initial visit? Select all that apply.
- A. Mr. Pirolla is looking into adaptive devices (hearing aid, new glasses) to make socializing more possible for him.
- B. Mrs. Pirolla reports that she no longer has to yell to get her husband's attention and that the TV can be kept at a moderate volume.
- C. Mr. Pirolla regains 20/20 vision.
- D. Mrs. Pirolla reports that her husband seems to be enjoying family visits more and no longer withdraws to his study.
- E. Mrs. Pirolla reports that they both seem content with their "new normal" social life.
- F. Mrs. Pirolla reports that they have pretty much resumed their active social life.
Correct Answer: A,B,D,E
Rationale: The goal of the interventions is to improve Mr. Pirolla's ability to socialize despite sensory impairments. Using adaptive devices (A), improved communication without yelling (B), enjoying family visits (D), and contentment with their adjusted social life (E) indicate successful management of sensory deficits. Regaining 20/20 vision (C) is unrealistic for age-related sensory loss, and resuming a fully active social life (F) may not be feasible given his limitations.
A school nurse is performing vision screenings on middle-school children. The nurse notes a student squinting and that their visual acuity using a Snellen's eye chart is 20/160. When questioned, the student states their grades have dropped, and they are having difficulty completing work on time. What is the best recommendation for the nurse to make to the student's guardian(s)?
- A. Purchase or prepare a calendar to organize assignments.
- B. Ensure the student understands what is expected of them in each class.
- C. Seek medical attention if the student has eye pain while at home.
- D. Obtain an appointment with an eye professional for further evaluation.
Correct Answer: D
Rationale: Visual acuity of 20/160 indicates myopia; this student sees at 20 feet what a person with normal vision can see at 160 feet. The impaired vision is interfering with their academic performance, and further assessment by an eye care professional is indicated.