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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.
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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 school nurse is performing vision screenings on middle-school children. The nurse notes a student squinting and that their visual acuity using a Snellen's eye chart is 20/160. When questioned, the student states their grades have dropped, and they are having difficulty completing work on time. What is the best recommendation for the nurse to make to the student's guardian(s)?
- A. Purchase or prepare a calendar to organize assignments.
- B. Ensure the student understands what is expected of them in each class.
- C. Seek medical attention if the student has eye pain while at home.
- D. Obtain an appointment with an eye professional for further evaluation.
Correct Answer: D
Rationale: Visual acuity of 20/160 indicates myopia; this student sees at 20 feet what a person with normal vision can see at 160 feet. The impaired vision is interfering with their academic performance, and further assessment by an eye care professional is indicated.
A nurse observes that a patient with a history of cataracts is sitting closer to the television than usual. When assessing the patient, which additional findings will the nurse anticipate?
- A. Clouding of the lens in one or both eyes
- B. Eye pain when performing close work
- C. Abrupt loss of vision
- D. Loss of central vision
Correct Answer: A
Rationale: Cataracts, clouding of the crystalline lens, cause altered sensory reception by interfering with the patient's ability to receive visual stimuli. The other options are not characteristic of cataracts.
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.
A nurse in a long-term care facility notes that a patient with limited activity related to severe rheumatoid arthritis is at risk for sensory deprivation. Based on this information, which interventions will the nurse include in the care plan? Select all that apply.
- A. Using a lower tone when communicating with the patient
- B. Providing interaction with children and pets
- C. Decreasing environmental noise
- D. Ensuring that the patient shares meals with other patients
- E. Discouraging the use of sedatives
- F. Providing adequate lighting and clear pathways of clutter
Correct Answer: B,D,E
Rationale: For a patient who has sensory deprivation, the nurse provides interaction with children and pets, ensures that the patient shares meals with other patients, and discourages the use of sedatives. Using a lower tone (pitch) of voice is appropriate for a patient with a hearing deficit. Decreasing environmental noise helps relieve sensory overload. Providing adequate lighting and removing clutter is an intervention for a vision deficit.