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Which instruction should the nurse discuss with the client when completing a sensory assessment regarding proprioception?
- A. Instruct the client to lie flat without a pillow during the assessment.
- B. Instruct the client to keep both eyes shut during the assessment.
- C. During the assessment the client must be in a treatment room.
- D. Keep the lights off during the client's sensory assessment.
Correct Answer: B
Rationale: Closing eyes during proprioception testing (e.g., Romberg test) isolates balance to proprioceptive input. Lying flat, treatment rooms, and lights off are irrelevant.
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The nurse speaks with the client who recently learned that cataracts are developing in both of the client's eyes. Which statement made by the client should the nurse correct?
- A. It is important that I schedule my surgery as soon as possible.
- B. Usually surgery is performed on each eye at different times.
- C. My own lens will be removed when I have cataract surgery.
- D. An intraocular lens may be inserted with the surgical procedure.
Correct Answer: A
Rationale: Although there is reduced vision with beginning cataract development, a person can wait until vision worsens before having surgery. When vision is reduced to the extent that ADLs are affected, surgery should be performed as soon as possible. If both eyes have cataracts, usually the eyes are treated in separate procedures. Surgery for a cataract involves removal of the client's lens, and in most situations, the lens is replaced with an intraocular lens.
The nurse is administering eardrops to a six (6)-year-old client. Which indicates the nurse is aware of the correct method for instilling eardrops to a child?
- A. Pull the pinna upward only to instill the eardrops.
- B. Pull the pinna to a neutral position to instill the eardrops.
- C. Pull the pinna upward and backward prior to instilling the drops.
- D. Pull the pinna downward and forward to instill the drops.
Correct Answer: D
Rationale: For children under 3, pulling the pinna down and back straightens the ear canal; for older children like a 6-year-old, down and back is still appropriate. Upward or neutral pulls are incorrect.
An adult man fell off a ladder and hit his head and lost consciousness. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. The nursing care plan will most likely include which of the following?
- A. Elevate head of bed 15 to 30 degrees
- B. Encourage fluids to 1000 mL every eight hours
- C. Assist the client to cough and deep breathe every two hours
- D. Perform chest physical therapy every four hours while awake
Correct Answer: A
Rationale: Elevating the head of the bed 15 to 30 degrees promotes gravity drainage of fluid and reduces cerebral edema. Coughing, forcing fluids, and chest physical therapy may increase intracranial pressure and are contraindicated.
The nurse is concerned that the Caucasian client experiencing a stroke may have impaired hearing. Which observations of the client's behavior prompted this concern? Select all that apply.
- A. Nods and agrees to all statements made by the nurse
- B. Asks for more information about the therapy schedule
- C. Slow to respond verbally but answers questions appropriately
- D. Speaks in an excessively loud tone of voice
- E. Leans in toward the nurse when the nurse speaks
Correct Answer: A,D,E
Rationale: Nodding and agreeing to all statements, speaking loudly, and leaning toward the speaker suggest hearing impairment. Asking for schedule details and slow but appropriate responses do not indicate hearing issues.
The client recently diagnosed with age-related macular degeneration (AMD) in both eyes returns to the clinic for a follow-up appointment. Which assessment will the nurse be certain to include during the visit?
- A. Stools for occult blood
- B. Blood glucose levels
- C. Screening for depression
- D. Screening for hearing loss
Correct Answer: C
Rationale: The nurse should assess for depression because loss of vision can affect functional ability, mood, and quality of life. Depression frequently develops within a few months after AMD is diagnosed in both eyes. GI bleeding, blood glucose, and hearing loss are not directly related to AMD.