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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 elderly male client tells the nurse, 'My wife says her cooking hasn't changed, but it is bland and tasteless.' Which response by the nurse is most appropriate?
- A. Would you like me to talk to your wife about her cooking?
- B. Taste buds change with age, which may be why the food seems bland.
- C. This happens because the medications sometimes cause a change in taste.
- D. Why don't you barbecue food on a grill if you don't like your wife's cooking?
Correct Answer: B
Rationale: Age-related taste bud decline reduces taste perception, a common issue in the elderly. Talking to the wife, blaming medications, or suggesting grilling are less appropriate.
The client with severe otitis media and mastoiditis is prescribed levofloxacin IV, 250 mg every 12 hours. The medication is diluted in 100 mL of NS. To deliver the antibiotic in 30 minutes, the nurse must infuse the solution at a rate of how many mL per hour?
- A. 200
Correct Answer: A
Rationale: The rate of IV infusion is calculated as follows: 100 mL over 30 minutes equals X mL over 60 minutes. Thus, 100/30 = X/60, so X = (100 × 60) / 30 = 200 mL/hr.
The nurse writes the diagnosis 'risk for injury related to impaired balance' for the client diagnosed with vertigo. Which nursing intervention should be included in the plan of care?
- A. Provide information about vertigo and its treatment.
- B. Assess for level and type of diversional activity.
- C. Assess for visual acuity and proprioceptive deficits.
- D. Refer the client to a support group and counseling.
Correct Answer: C
Rationale: Assessing visual and proprioceptive deficits identifies factors contributing to vertigo-related falls, enhancing safety. Information, activities, and referrals are secondary.
The nurse is questioning the client about vision changes. Which symptom indicates that the client may be developing a cataract?
- A. Blurred vision, worsening at night
- B. Shooting pain in the back of one eye
- C. Increased frequency of headaches
- D. Seeing spots in the vision field of one eye
Correct Answer: A
Rationale: The lens opacity from a developing cataract diminishes vision. Blurriness and decreased night vision are early symptoms. Shooting eye pain is often associated with a subarachnoid hemorrhage, not a cataract. Headaches are not associated with cataract formation. Floating dark spots in the vision field are associated with bleeding within the eye that occurs with detached retina.
Which referral is most important for the nurse to implement for the client with permanent hearing loss?
- A. Aural rehabilitation.
- B. Speech therapist.
- C. Social worker.
- D. Vocational rehabilitation.
Correct Answer: A
Rationale: Aural rehabilitation addresses communication strategies and hearing aids, critical for permanent hearing loss. Speech therapy, social work, and vocational rehab are secondary.