ch 27 Flashcards
A 75-year-old woman walks into the emergency department with complaints of “not feeling well.” Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings?
a. Normal in the older adult
b. A need for the patient to be evaluated for cognitive impairment
c. A side effect of anti-hypertensive medication
d. Pathologic impairment of sensory responses
ANS: D
This degree of sensory impairment at this age is not expected. Lack of sensation does not imply lack of knowledge, but rather decreased ability to perceive the stimuli. Anti-hypertensive medication does not typically cause decreased skin sensation. This is more common in antineoplastic drugs. Most likely the patient has diabetes, which is causing decreased sensation. Not feeling well is secondary to a change in blood sugar as a result of the wound response.
The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements?
a. “This will help us to identify your baby’s risk for ear infections the first year of
life.”
b. “Hearing is important so your baby hears and responds to your voice, which
makes you feel like a mother.”
c. “Socialization skills include the need to hear in order to interpret the emotional
aspect of the words that are spoken to your child.”
d. “Imitation of sounds is the first step in language development, and it is important
to identify alterations early.”
ANS: D
Newborn screening of hearing does not identify risk of infection but only of sensory responses. The baby’s response to the mother is important to bonding, but this not the most important reason to evaluate hearing. Likewise, socialization and tone recognition are functions of hearing, but the most significant reason to test hearing is to identify losses and provide compensatory ways to encourage language development.
An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse’s best response?
a. “Your wife should increase the spices in your food, as the pneumonia changes
your sense of smell.”
b. “Notify your doctor immediately, because this is a concerning reaction to the
medication.”
c. “You need to take an appetite stimulant, as your body will need good nutrition to
recover from the infection.”
d. “You should see an improvement in the next week or so. Call if this continues.”
ANS: D
Many medications cause a change in sense of taste, including antibiotics. This is temporary and does not require interventions. Pneumonia affects the lower respiratory tract, and is less likely to cause change in smell. The short-term effects of the antibiotic should not necessitate major concern regarding diet intake, including stimulants.
An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following?
a. “I will make sure that dad always wears warm socks.”
b. “Dad needs to wear his glasses so he can delay the onset of macular degeneration.”
c. “I will ask the home health aide to carefully inspect dad’s feet every day when she helps him bathe.”
d. “We will give him only warm foods, so that he doesn’t burn his mouth.”
ANS: C
Diabetes increases risk of peripheral neuropathy, and it is hard to inspect one’s own feet. Though socks that fit well are important, warmth is not the main issue. Glasses do not affect the onset of eye disorders, including macular degeneration. The sensory deficit regarding perception of heat and cold is usually associated with the distal extremities.
The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse’s best action to provide recreational activities during the rehabilitation phase?
a. Place the television to the left or right of patient’s visual field.
b. Encourage the patient to learn braille.
c. Suggest use of talking books.
d. Provide headphones for listening to music.
ANS: C
Talking books would provide a quick, short-term means of entertainment. Braille might be recommended as a long-term solution to visual deficits. The placement of the television is not helpful with low acuity, unless the patient has macular degeneration. Headphones may be nice, but the patient has a visual deficit and no indication that hearing is a problem.
The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the nurse’s priority action?
a. Notify the physician.
b. Document the finding in the records.
c. Recheck the reflex after several hours.
d. Monitor the eye movements and pupil reactions closely.
ANS: A
The absence of the red reflex suggests the presence of congenital cataracts, which is an abnormal finding. It will not change in several hours, nor do the eye movements and pupil reaction provide significant changes in this situation.
The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction?
a. “I will take my child to the audiologist because he doesn’t seem to hear me except
when I look directly at him.”
b. “Both of my children have the same eye medication, which is a real bonus,
because I only need to buy one bottle.”
c. “Making my child wear ear plugs when she goes to a rock concert may save her
hearing!”
d. “I see now why when my child has a cold, he complains about everything tasting
blah!”
ANS: B
Each person should always have their own eye medication to prevent infection transfer between them. The child who only hears with direct visional contacts may be lip-reading and have a hearing loss. Exposure to loud noises is known to cause hearing loss. Sense of taste and smell can be altered by upper respiratory infections.
During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient’s wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure?
a. Tympanoplasty
b. Irrigation of the ear
c. Pure tone test
d. Otoscopic exam by a specialist
ANS: B
The symptoms are consistent with blockage of the ear canal with cerumen, which then needs to be removed by irrigation, so that further examination of the ear drum and hearing can be accomplished. A tympanoplasty is only warranted if there has been a perforation, which is unknown at the present.
