Nokea
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.
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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 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).
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 caring for a patient with a severe hearing deficit who reads lips and uses sign language. Which nursing intervention would best prevent sensory alterations for this patient?
- A. Turning the radio or television volume up very loud and closing the door to his room
- B. Preventing embarrassment and emotional discomfort as much as possible
- C. Providing daily opportunities for them to participate in a social hour with six to eight people
- D. Encouraging daily participation in exercise and physical activity
Correct Answer: C
Rationale: Providing opportunities for the patient to socialize builds on their strength of being able to lip-read and helps prevent sensory deprivation from hearing loss.
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.