Nokea
The nurse is assessing the client’s sensory system. Which assessment data indicate an abnormal stereognosis test?
- A. The client is unable to identify which way the toe is being moved.
- B. The client cannot discriminate between sharp and dull objects.
- C. The toes contract and draw together when the sole of the foot is stroked.
- D. The client is unable to identify a key in the hand with both eyes closed.
Correct Answer: D
Rationale: Abnormal stereognosis is the inability to identify objects (e.g., a key) by touch with eyes closed, indicating parietal lobe dysfunction. Toe movement, sharp/dull, and Babinski reflex test other functions.
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The nurse completed teaching the client with a corneal abrasion about proper care of the injury. Which statements indicate that the client understood the teaching? Select all that apply.
- A. I should promptly report a sudden absence of pain.
- B. I should keep my affected eye uncovered when up.
- C. I should insert the eye drops 10 to 15 seconds apart.
- D. I should leave the eye patch in place for 24 hours.
- E. I will avoid rubbing my affected eye or the eye patch.
Correct Answer: D,E
Rationale: Patching the eye for 24 hours reduces irritation and promotes healing. Avoiding rubbing prevents reinjury. Sudden absence of pain, keeping the eye uncovered, and short intervals between drops are incorrect.
How should a nurse walk a client who is blind?
- A. Stand slightly behind the client and tell her when to turn
- B. Stand slightly behind and to the side of the client and guide her by holding her hand
- C. Walk slightly ahead with the client's arm inside the nurse's arm
- D. Walk beside the client and gently guide her by grasping her elbow
Correct Answer: C
Rationale: Walking slightly ahead with the client's arm inside the nurse's arm provides guidance and safety for a blind client.
What should the nurse include when teaching the client with Parkinson's disease?
- A. He should try to continue working as long as he can remain sitting most of the day.
- B. Drooling may be reduced somewhat if he remembers to swallow frequently.
- C. He should return monthly for lab tests, which will predict the progression of the disease.
- D. Emotional stress has no effect on voluntary muscle control in clients with Parkinson's disease.
Correct Answer: B
Rationale: Frequent swallowing can reduce drooling, a common symptom in Parkinson's disease, improving comfort and social interaction.
Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration?
- A. Move the big toe up and down and ask in which direction the vibration is felt.
- B. Place a tuning fork on the big toe and ask if the vibrations are felt.
- C. Tap the client's cheek with the finger and determine if vibrations are felt.
- D. Touch the arm with two sharp objects and ask if one (1) vibration or two (2) is felt.
Correct Answer: B
Rationale: Placing a tuning fork on the big toe assesses vibration sense (via dorsal column pathways), not cranial nerves directly, but is the correct technique. Other options assess different sensations.
The client with a retinal detachment has just undergone a gas tamponade repair. Which discharge instruction should the nurse include in the teaching?
- A. The client must lie flat with the face down.
- B. The head of the bed must be elevated 45 degrees.
- C. The client should wear sunglasses when outside.
- D. The client should avoid reading for three (3) weeks.
Correct Answer: A
Rationale: Face-down positioning maintains gas tamponade pressure on the retina, aiding reattachment. Elevation, sunglasses, and reading restrictions are secondary or incorrect.