Exam 3 - Review 2 Flashcards
Which behavior by a parent indicates an understanding of teaching regarding stimuli used to develop the infant’s auditory nervous system?
A. Cuddling
B. Speaking
C. Feeding
D. Soothing
B. Speaking
For a patient with impaired tactile perception, which nursing diagnosis would be considered of highest priority?
A. Self-care deficit: dressing and grooming
B. Impaired adjustment
C. Risk for injury
D. Activity tolerance
C.
Which of the following methods would the nurse plan to use to assess kinesthetic deficit in a patient?
A. Instruct patient to read from the Snellen chart
B. Ask the patient to close their eyes and identify smells
C. Have the patient perform alternating rapid movements
D. Touch the patient with a wisp of cotton
C
Which intervention is appropriate for the patient with a nursing diagnosis of disturbed sensory perception: gustatory?
A. Limit oral hygiene to one time a day
B. Teach the patient to combine foods in each bite
C. Assess for sores or open areas of the mouth
D. Instruct the patient to avoid salt substitutes
C
Which instruction would the nurse include when providing discharge teaching for a patient who has a serious visual deficit?
A. Install blinking lights to alert the patient of phone call
B. Have gas appliances inspected regularly to detect gas leaks
C. Wear properly fitting shoes and socks
D. Avoid using throw rugs on the floors
D
A patient tells the nurse that since starting a new medication, they suffer from excessive dry mouth. Which assessment would be needed to plan interventions for the symptom?
A. Asking the patient whether foods taste different now
B. Checking patient’s sense of smell
C. Having the patient stand to check for balance
D. Assessing for history of seizures
A
Which intervention is helpful when caring for a patient with impaired vision?
A. Suggest that the patient use bright overhead lighting
B. Advise the patient to avoid wearing sunglasses when outdoors
C. Do not offer long-print books because this may embarrass the patient
D. Place the patient’s eyeglasses within easy reach
D
Which of the following is a priority nursing diagnosis for a patient with visual impairment?
A. Self-neglect
B. Social isolation
C. Risk for falls
D. Risk for imbalanced nutrition: less than body requirements
C
Which factors in a patient’s health history place them at risk for hearing loss? Select all
A. Being an older adult
B. Childhood chickenpox
C. Frequent otitis media
D. Diabetes millitus
E. Congenital rubella
A, C, E
Which findings lead the nurse to suspect sensory overload in a patient in the intensive care unit? Select all
A. Disorientation
B. Restlessness
C. Hallucination
D. Depression
E. Preoccupation with somatic complaints
A, B
Which actions would the nurse take to prevent sensory overload? Select all
A. Leave the TV on low to block other noises
B. Minimize ambient light in patient’s room
C. Plan care to provide periods of sleep
D. Speak with a moderate tone of voice
E. Restrict caffeine intake during hospitalization
B, C, D, E
Which interventions are necessary to promote patient safety in an unconscious patient?
A. Talk to patient while providing care
B. Incorporate more touch in the plan of care
C. Provide frequent eye care if the blink reflex is absent
D. Keep the side rails up and the bed in low position
E. Perform diligent oral care by irrigating with diluted mouthwash
A, C, D
A nurse on a medical unit is caring for a client who suddenly becomes confused and drowsy. Additional data includes pulse 100/min, respiratory rate 24/min, BP 132/76 mm Hg, and temperature 98.2 F. Which of the following actions should the nurse perform?
A. Complete a neurological check
B. Administer the prescribed PRN antihypertensive meds
C. Increase the client’s fluid intake
D. Hold the client’s evening dose of digoxin
A. Complete neurological check
A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action of the nurse?
A. Speak using his usual tone of voice
B. Stand directly in front of the client
C. Rephrase statements the client does not hear
D. Determine if the client uses hearing aids
D
A nurse is assessing a client who is experiencing complications due to immobility. Which of the following findings should the nurse expect? (select all)
A. Polyuria
B. Diarrhea
C. Contractures of the extremities
D. Pressure ulcers
E. Crackles in the lungs
C, D, E
