Nokea
A nurse observes that a patient with a history of cataracts is sitting closer to the television than usual. When assessing the patient, which additional findings will the nurse anticipate?
- A. Clouding of the lens in one or both eyes
- B. Eye pain when performing close work
- C. Abrupt loss of vision
- D. Loss of central vision
Correct Answer: A
Rationale: Cataracts, clouding of the crystalline lens, cause altered sensory reception by interfering with the patient's ability to receive visual stimuli. The other options are not characteristic of cataracts.
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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.
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 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.
A nurse is assessing a patient for gustatory disturbances. Which question asked by the nurse would be appropriate for this assessment?
- A. "Have you been experiencing any loss of taste or strange tastes lately?"
- B. "Have you smelled odors lately that others cannot smell?"
- C. "Can you tell me what object I am placing in your hand right now?"
- D. "Have you found it difficult to communicate verbally?"
Correct Answer: A
Rationale: When the nurse asks: "Have you been experiencing any strange tastes lately?" the nurse is assessing for gustatory disturbances. The question: "Have you smelled odors lately that others cannot smell?" assesses for olfactory disturbances. When the nurse asks: "Can you tell me what I am placing in your hand right now?" the nurse is assessing for tactile disturbances. The question "Have you found it difficult to communicate verbally?" assesses for transmission-perception-reaction.
A patient is in the late stages of AIDS, which has affected their brain function and memory. The patient reports loneliness because his friends "are afraid to visit." Based on this data, what nursing intervention would best help meet the patient's need for sensory stimulation?
- A. Providing stimulation through music, television, or movies
- B. Assessing the patient's hearing and vision to ensure optimal function
- C. Ensuring the patient is able to transmit their message to others
- D. Arranging for a volunteer to sit with the patient each day
Correct Answer: D
Rationale: This patient is receiving decreased environmental stimuli (e.g., from lack of visitors) and may experience problems with reception because of brain involvement. Arranging for a volunteer to sit with the patient provides social interaction, addressing the loneliness and sensory deprivation.