Nokea
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.
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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.
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 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 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 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.