HESI Sensory Function

Question 1

Assessment
During the initial interview, the nurse inspects the external anatomy of the eye. The nurse notes that the cornea looks cloudy and an arcus senilis is seen around the cornea.

What action should the nurse take first?

Answer 1

Assess where the cornea looks thickened and raised and document the finding.

Rationale: the lipid accumulates, the cornea maleic thickened and raised. The assessment findings should be documented in the electronic medical record.

Question 2

During the assessment of the client hearing, the nurse performs a series of tests, including clients, ability to hear, whispered, and conversational sounds.

How would the nurse assess for the presence of tinnitus?

Answer 2

Ask the client if he ever hears ringing in his ears.

Rationale: tonight, this is the presence of ringing in the ears, which is often associated with hearing loss.

Question 3

The client seems nervous and asks for a glass of water. After taking a drink, the client attempts to set the glass down, but places the glass on the edge of the counter, causing it to crash to the floor.

Follow up on the situation, which assessment would provide the most useful data?

Answer 3

Visual field and depth perception

Rationale: Under or overreaching for objects is an indication of a visual deficit. Assessment of visual field and depth perceptional provide the most useful data related to this situation.

Question 4

The clients visual activity is measured using a snow and chart. The reading obtained is 20/200 in the right eye and 20/80 in the left eye.

How should the nurse explain these findings to the client?

Answer 4

Results reflect, nearsighted, especially in the right eye.

Rationale: the larger the denominator (bottom number), the poor visual acuity. This is commonly referred to as being nearsighted. Standing at 20 feet, the client can read what a person with normal vision can you read it for the distances, such as 80 feet (left eye) or 200 feet (right eye). Nearsightedness (myopia) occurs when the eye bends the light and convergent in front of the retina where the near vision is normal, but distance vision is poor.

Question 5

Nursing process: assessment/communication
As the interview continues, the nurse knows the client is very pleasant and no their head in agreement with all the nurses statements, but does not respond to simple requests during the assessment.

Which nursing diagnosis is best supported by the data available?

Answer 5

Disturbed sensory alteration (auditory).

Rationale: clients with impaired hearing, often smile, and not in agreement with a person conversing even though they’re unable to clearly hear the conversation. Appearing to be in attentive, speaking loudly, and difficulty following directions are other indications of a disturbance and auditory sensory function.

Question 6

In identifying this problem, the nurse clusters the subjective and objective assessment data, and compares it with which information?

Answer 6

Defining characteristics of the problem.

Rationale: The assessment data is compared with the divining characteristics of the problem to ensure that the correct problem is being identified.

Question 7

The nurse plans to assess subjective data about the clients hearing loss. Follow up with the situation, which assessment will provide the most useful data? (SATA)

Answer 7

Gradual loss of hearing all at once.

Rationale: The nurse wants to know the onset of the hearing loss. Presbycusis is the term for gradual onset, hearing loss, which is usually worse in noisy environments.

Evidence of decreased hearing.

Rationale: assessing the character of the hearing loss with this question. Mark glosses at low intensity, but sound actually becomes painful when a speaker repeats and loud voice.

Hearing only certain sounds.

Rationale: The nurses assessing the character of hearing loss. Asking if the client has recently traveled by airplane or had an upper respiratory infection, would be useful information to obtain.

Vibrations heard unequally with tuning fork.

Rationale: When the RN uses a tuning fork to perform the Weber test, this is considered objective data.

Question 8

Music is playing loudly through the exam rooms intercom system. Another nurse enters the room and turns the music off before speaking with a client.

Which action should the nurse assessing the client implement?

Answer 8

Affirm that the other nurses actions may assist the clients ability to hear by eliminating background noise.

Rationale: Clients, with a hearing impairment, have difficulty hearing conversation when there is background noise, such as music or other conversations.

Question 9

Pharmacologic Therapies
The client is referred to vision and hearing specialist for more in-depth evaluation and treatment. Medical diagnosis of cataracts is identified as the cause of the clients visual deficit. Noise induced hearing loss and changes related to aging are identified as the causes of the clients auditory deficit. The client is scheduled for eye surgery in three weeks. The nurse teaches the client about the administration of the eyedrops. He will need to use. The healthcare provider Prescribes 2TTS in the right eye twice a day.

What direction should the nurse provide the client?

Answer 9

Place two drops in the right eye every 12 hours

Rationale: These are the correct directions.

Question 10

The client demonstrates the eyedrop procedure by holding the outer campus up and back, inserting the drops without touching the eye with the dropper, and applying light pressure over the inner campus.

What action should the nurse take?

Answer 10

Educate the client by demonstrating to pull the conjunctival sac down while administering the medication.

Campus is not held during the administration of eyed Dropps. The conjunctive sac at the bottom of the eye is pulled downward, so the medication can be administered without directly applying it to the cornea.

Question 11

Risk potential
After learning to self administer eyedrops, the client is preparing to go home. The nurse has identified that the client is at risk for injury because of his visual and auditory sensory deficits.

Which action should the nurse implement?

Answer 11

Consult with the case manager to help the client assess his home for safety hazards.

Rationale: this is the best intervention to reduce the clients risk for injury. The nurse can provide a home safety checklist as a reference to ensure that the clients home is safe for a person sensory deficits.

Question 12

The client reports to the nurse that they fill the home is free of hazards. The client states that they have some decorative throw rugs on the top of the hardwood floors, but they can’t slide, because there is padding underneath them that prevent sliding.

When teaching a client about home, safety, which instruction is most important for the nurse to include?

Answer 12

Removal of the rugs prevents, accidental, tripping and falling.

Rationale: The client with a visual deficit may trip on loose edges, chords, rat spots, or unexpected items left on the floor. Explaining the rationale for desired actions, such as the removal of throw rugs, in increases client compliance.

Question 13

Psychosocial integrity
The client becomes angry after the nurse provides the list of home safety checks that should be performed and suggests removing the thugs. The client yells telling the nurse that they think they’re helpless, old, and can’t take care of themselves anymore.

What action should the nurse implement?

Answer 13

Stay in the room, sitting with the client.

Rationale: the nurse needs to recognize the reasons behind the clients, angry outburst, and provide a therapeutic response, such as presence and silence.

Question 14

The nurse recognizes that the client is fearful and angry. How should the nurse demonstrate a caring response to the client?

Answer 14

Give full attention to what the client is saying.

Rationale: Active listening, includes giving full attention to what the client is seeing and provides a caring presence.

Question 15

The nurse interprets the clients, angry outburst as an indication that he is afraid that he might become a dependent upon others of his sensory deficits continue. Which nursing diagnosis should be added to the plan of care?

Answer 15

Self-care deficit.

Rationale: The nurse is an analysis of the clients behavior reflects the fear that they may become dependent on others, creating feelings of diminished self-esteem, which may lead to impaired ability to perform or complete activities of daily living for oneself, such as feeding, dressing, bathing, toileting.

Question 16

Nursing process: assessment
During the preoperative evaluation for the clients cataract surgery, a chest x-ray reveals a small mass and the clients left along. Biopsy reveals that the mass is cancerous. The clients cataract surgery is postponed, and they begin chemotherapy. After the second round of chemotherapy, the nurses assessment reveals the client has lost 10 pounds. The client states that smells make him sick to the stomach and that food has no taste. To improve the clients, appetite, friends, often cook meals for them, keeping the food, soft, and bland.

What client teaching should the nurse provide?

Answer 16

Add seasonings to the bland food to stimulate the taste buds

Rationale: the addition of seasonings, such as lemon juice, come enhances, food, flavor, and stimulates taste sensation.

Question 17

What additional teaching can the nurse provide to reduce the problems related to the clients sense of smell?

Answer 17

Suggest that the meals be prepared at the friends home and then delivered to the client ready to eat.

Rationale: Removing the aroma of cooking food, eliminates a major trigger for the client with a heightened sense of smell.

Question 18

Nursing process assessment
The client reports that his fingers often feel numb or like “pins and needles.” Assessment reveals 3+ radio pulses bilaterally with capillary refill of one second.

How should the nurse document these findings?

Answer 18

Paresthesia.

Paresthesia refers to abnormal sensation, including sensation, such as burning, numbness, or tingling.

Question 19

The nurse plans to assess the clients ability to discriminate sensation. What technique should the nurse use?

Answer 19

Touch the extremities with items, and ask the client to describe the sensation felt.

Rationale: After the client closes his eyes, the nurse touches the extremities With items that are hot, cold, sharp, and dull. The client identifies the sensation felt, which assesses discrimination of sensation.

Question 20

The nurse tells the client that his altered touch sensation is the result of his chemotherapy. Nurse is concerned about home safety while the clients ability to discriminate sensation is diminished. The nurse suggests that the client label all his hot water fixtures with tape for easy identification. He agrees this is a good idea since his plumbing fixtures are old and the “H” and “C” faded.

What color tape is best for the client to use to label his hot water faucets?

Answer 20

Orange

Rationale: As people age, their ability to distinguish colors diminishes. Safety hazards should be marked with colors that are easy to distinguish, such as orange, red, or yellow.

Question 21

Safe and effective care environment
The client has completed his chemotherapy and is now scheduled for surgery to remove the mass. The client paresthesia has not diminished in their hands. The nurse starts an IV prior to his surgery, but the IV infiltrates. The nurse wraps, a warming blanket around the arm in hand to reduce the swelling, but forget to remove the pad. And another nurse later removes the pattern of small blisters on the clients palms as the result of the heating pad being left in place too long.

What is the legal significance of this situation?

Answer 21

The nurse who applied the heating pad has demonstrated malpractice.

The application of heat is a procedure based on standards of care for which the nurses accountable. Malpractice occurs when the care provided by professional does not seem to meet those standards of care. Additionally, the nurse is responsible for recognizing that this client is at high risk for injury related to his altered sensation. “paresthesia” and therefore to take the necessary precautions to prevent injury.

Question 22

Which documentation is important for the nurse to include in the clients medical record regarding the unfortunate situation with the heating pad?

Answer 22

Management of the client blisters.

Rationale: The nurse documents, the client, symptoms and actions taken, including notification of the healthcare care provider, prescriptions received, interventions, implemented, and follow up evaluation.

Question 23

The nurse, caring for the client understands. The treatment of burns is related to the severity of the injury. Which factors determine the severity of a burn? (SATA)

Answer 23

-Depth of burn
-extent of burn, calculated and percentage of total body surface area
-Location of burn
-Client risk factors

Rationale: these are all factors used to determine the severity of a burn.

Question 24

Using the rule of nines, during the initial assessment of the burn, what should the nurse calculate as the client percentage of TPA affected?

Answer 24

1%

Rationale: The clients hand, including fingers is approximately 1% of TBSA.

Question 25

Rule of Nines:

The rule of nines estimation of body service area burned is based on assigning percentages to different areas of the body.

Answer 25

-The entire head is estimated as 9% (4.5% for anterior and 4.5% for posterior).

-The entire trunk is estimated at 36% and could be further broken down into 18% for anterior components and 18% for the back.

-The anterior aspect of the trunk can further be divided into chest (9%) and abdomen (9%).

-The upper extremity is total 18% and 9% for each upper extremity. Each upper extremity can further be divided into anterior (4.5), and posterior (4.5).

-The lower extremities are estimated at 36%, 18% for each lower extremity. Again this can be further divided into 9% for the anterior 9% for the posterior aspect.

-The groin is estimated at 1%

Question 26

The nurse should anticipate implementing which intervention for the clients thermal pressure thickness burn?

Answer 26

Cover with a dry dressing

Rationale: initial treatment of a thermal, partial thickness burn is a dry dressing.

Question 27

Nursing process intervention:
The client is taken to the operating room, and the mass is successfully removed. After surgery, the client is transferred to room on the surgical unit near the nursing station. In the middle of the night, the client awaken and seems restless and confused. The room is dark, except for the light that filters through the almost totally closed during the hallway. Which nursing action will best reduced the clients confusion?

Answer 27

Address the client by name, stating where the client is and what time it is.

Rationale: the client was sensory impairment, may become easily confused in a strange environment, especially at night, when influenced by postoperative pain and medication’s. The RN should re-orient the client, speaking with a calm and reassuring voice.

Question 28

The nurses action calms the client. Prior to leaving the room, what action(s) should the nurse implement? (SATA)

Answer 28

Turn on the bathroom light

Rationale: a small amount of indirect lighting, while unable to client, identify the surroundings upon weakening, reducing confusion without providing excessive sensory stimulation.

Ensure the client can easily reach the call bell

Rationale: The safety procedure should be followed before leaving the room.

Ask the client if they would like music
therapy or massage

Rationale: Providing music therapy and massage encourages relaxation in a client which may assist decreasing restlessness

Question 29

Reduction of risk potential
The remainder of the clients hospitalization is uneventful, and he prepares for discharge. Discharge teaching includes the review of home safety measures since the client continues to experience, auditory and visual sensory deficits. The client tells the nurse that their grandson has taken over the family Pharm. The client remarks that the grandson would be hard of hearing to someday because it happened to all the farmers and their family.

How should the nurse respond?

Answer 29

Advise the client to tell his grandson to his protective hearing devices whenever he’s working with loud machinery, to preserve his hearing.

Rationale: This response, enhances physiological integrity for the clients family member and is a proactive health, promotion and disease prevention. Although hearing loss may have a genetic component, it is often preventable, as in the situation involving Fred’s grandson.

Question 30

Case outcome
The client is discharged and completes their recovery from the surgery. The clients altered, taste, smell, and tactile senses return to normal. Once recovered, the client has cataract surgery and is fitted for hearing aid. The client enjoys helping their grandson run the family, farm, and everyone in the family now where is protective hearing devices went around loud machinery.