Nokea
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.
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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 home care nurse is visiting a group of patients. Which patient does the nurse identify as having the highest risk for sensory deprivation?
- A. Older adult confined to bed at home after a stroke
- B. Adolescent in an oncology unit working on homework
- C. Pregnant patient in active labor
- D. Toddler awaiting same-day surgery in a playroom
Correct Answer: A
Rationale: The patient confined to bed rest at home has a high risk for greatly reduced environmental stimuli. The other patients are in environments in which environmental stimuli are present.
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.
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.