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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.
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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 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 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.
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.