Nokea
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.
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In a group home where most residents have varying degrees of visual or hearing impairments and some are periodically confused, what nursing action is essential?
- A. Maintaining safety and preventing sensory deterioration
- B. Insisting that residents participate in as many self-care activities as possible
- C. Emphasizing and reinforcing individual patient strengths
- D. Encouraging reminiscence and life review in groups
Correct Answer: A
Rationale: Safety is a basic physiologic need that must be met before higher-level needs such as love and belonging, self-esteem, and self-actualization can be met.
A nurse in the neonatal intensive care unit (ICU) is planning care to reduce inappropriate sensory stimulation to their patients. Which interventions could the nurse include in the care plan? Select all that apply.
- A. Providing bright mobiles and objects for the neonate to look at
- B. Rocking the neonate frequently, especially when crying
- C. Maintaining reduced ambient light, similar to conditions in the womb
- D. Reducing vestibular stimulation, such as rocking
- E. Playing music or singing to the neonate to stimulate hearing
Correct Answer: C,D
Rationale: The neonatal ICU may be a source of excess sensory stimulation. It is recommended that medically fragile infants receive limited light (visual stimuli) to simulate being in the womb as well as reduced vestibular stimulation. The nurse avoids activities that promote stimulation in this population including soothing, holding, rocking, and changes of position (tactile and kinesthetic sensations), singing and speaking to the neonate (auditory sensations), and changing patterns of light and shade, such as through the use of mobiles and bright objects (visual sensations).
A school nurse is teaching a group of high school students about preventing hearing loss. What preventative actions does the nurse recommend? Select all that apply.
- A. Use earphones when listening to music, podcasts, or other programs.
- B. Do not insert objects such as cotton-tipped applicators into the ear.
- C. Avoid playing contact sports.
- D. Use ear protection when performing tasks with loud sounds.
- E. It is best to begin screening for hearing loss at age 18 years.
Correct Answer: B,D
Rationale: To prevent hearing loss, the nurse teaches students to avoid concentrating sound in the ear canal, such as when using earphones, and to use ear protection for loud activities. Inserting objects into the ear canal can cause damage.
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.
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.