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A nurse is caring for a patient with a traumatic spinal cord injury that resulted in paraplegia (paralysis) and sensory loss from the waist down. When obtaining data about this patient, what component of sensory function does the nurse plan to assess?
- A. Transmission of tactile stimuli
- B. Adequate stimulation in the environment
- C. Reception of visual and auditory stimuli
- D. General orientation and ability to follow commands
Correct Answer: A
Rationale: Trauma to the spinal cord can cause both motor and sensory loss, interfering with transmission of tactile stimuli. Although the other options may be assessed, they do not relate to the spinal cord injury.
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A nurse is providing information on smoking cessation at a hospital health fair. The nurse teaches that smoking cessation may help prevent what problem?
- A. Reduced vision due to macular degeneration
- B. Glare from cataracts
- C. Presbyopia and the need for corrective lenses
- D. Reduced auditory senses
Correct Answer: A
Rationale: Macular degeneration is the leading cause of blindness in older adults. Smoking is a known risk factor for its development.
A nurse is caring for an older adult who has a severe visual deficit related to glaucoma. Which nursing action is most appropriate when providing care for this patient?
- A. Assisting the patient to ambulate by walking slightly behind them and grasping the arm
- B. Concentrating on the patient's sense of sight and limit diversions that involve other senses
- C. Staying outside of the patient's field of vision when performing personal hygiene for them
- D. Cueing the patient when the conversation has ended and when leaving the room
Correct Answer: D
Rationale: When caring for a patient who has a visual deficit, the nurse should indicate when the conversation is over and when they are leaving the room to prevent confusion and promote safety.
A visiting nurse conducts a visit for an 11-month-old infant. The nurse finds the infant lying on the floor, rocking back and forth with a flat expression, and few vocalizations. Which nursing action would be appropriate at this time?
- A. Assessing the type of stimulation the infant has been receiving
- B. Removing the infant from the grandmother's care as the child has not progressed.
- C. Explaining that their negligence has resulted in the child's speech delays
- D. Taking no action, as this is expected behavior for an 11-month-old infant
Correct Answer: A
Rationale: Using the first step of the nursing process, assessment, the nurse determines if the types of stimulation given by the infant's parents validate that they understand the education provided at the parenting classes. The grandmother's reduced vision would not impact the child's speech. While the infant's development is not progressing, accusing the parents of negligence is premature.
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.
When caring for an older adult who repeatedly states their food does not taste as good as it used to, a nurse explains that which factors can contribute to loss of taste as patients age? Select all that apply.
- A. Decreased sense of smell
- B. Presbycusis
- C. Medications
- D. Diseases
- E. Tobacco use
- F. Presbyopia
Correct Answer: A,C,D,E
Rationale: As the patient ages, gustatory senses, along with sense of smell, some medications, and smoking can blunt the taste (gustatory sense). Presbycusis refers to the reduced ability to hear, and presbyopia refers to the inability of the lens to accommodate to near (or far) objects.