Chapter 29: Sensory Function My Nursing Test Banks

Chapter 29: Sensory Function

Meiner: Gerontologic Nursing, 5th Edition

MULTIPLE CHOICE

1. An older adult patient reports burning and itching eyes. On assessment, the nurse notes swelling of the eyelid margins bilaterally. What additional data are necessary to confirm the nurses suspicion of blepharitis?

a.

The patient reports visual disturbances such as rainbow halos.

b.

The eyelids are reddened from seborrhea.

c.

The patient is being treated with anticoagulants.

d.

Small corneal hemorrhages are present.

ANS: B

Blepharitis is a chronic inflammation of the eyelid margins that is commonly found in older adults. It can be caused by seborrheic dermatitis or infection. The symptoms include red, swollen eyelids, matting and crusting along the base of the eyelash at the margins, small ulcerations along the lid margins, and complaints of irritation, itching, burning, tearing, and photophobia.

DIF: Remembering (Knowledge) REF: Page 642 OBJ: 29-10

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

2. The morning of her scheduled cataract extraction and intraocular lens placement of the right eye, an older adult patient expresses concern that she will not remember her instructions for home care. Which statement is the best response to the patients concern?

a.

Is your family going to be here while youre in surgery?

b.

Are you anxious about the surgery?

c.

Ill reinforce the important points.

d.

We will provide you with written instructions.

ANS: D

Postoperative care requires teaching the patient and family home care procedures for the period after cataract surgery and should be given orally as well in written form. The patient may or may not have family present. Asking about anxiety could be important, but yes/no questions are not therapeutic. The nurses idea of what are the important points may differ from the patients.

DIF: Understanding (Comprehension) REF: Page 655 OBJ: 29-2

TOP: Teaching-Learning MSC: Physiologic Integrity

3. Your 88-year-old patient is hospitalized for a retinal detachment. He is on bed rest, and both eyes are covered with patches. Which nursing diagnosis takes priority at this time?

a.

Self-esteem disturbance related to decreased independence

b.

High risk for altered thought processes related to visual impairment

c.

High risk for injury related to altered sensory perception

d.

Impaired social interaction related to visual deficit

ANS: C

If the eyes are patched, safety precautions, such as keeping call lights, side rails, and necessary items within reach, must be instituted. Finally, assistance must be provided with activities of daily living (ADLs) and walking as needed to promote comfort and safety. The other diagnoses may be appropriate for selected patients.

DIF: Applying (Application) REF: N/A OBJ: 29-2

TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment

4. A 66-year-old patient has been diagnosed with type 2 diabetes mellitus and related vision loss. Which statement demonstrates the ability to manage her condition?

a.

I schedule my yearly eye examination for the week of my birthday.

b.

When I notice haloes around lights, Ill know Im developing a problem with retinopathy.

c.

My sister had diabetic retinopathy, and the vessels in her eyes were scarred.

d.

I understand that the eye problems need to be diagnosed with an ophthalmoscopic exam.

ANS: A

Patients with diabetes should have a yearly examination by an ophthalmologist. Scheduling the exam for the week of her birthday will keep the patient from forgetting to do so. The other statements are not related to management.

DIF: Evaluating (Evaluation) REF: N/A OBJ: 29-3

TOP: Nursing Process: Evaluation MSC: Health Promotion

5. A 77-year-old patient who is quiet and withdrawn may have a hearing deficit related to impacted cerumen. During the nursing assessment, the nurse confirms supporting evidence of the condition when noting:

a.

frothy drainage from the patients ears.

b.

patient reports of dizziness.

c.

patient reports of a feeling of fullness in the ears.

d.

gray, metallic-appearing tympanic membrane.

ANS: C

Patients with cerumen buildup may complain of ear fullness, itching, and difficulty hearing. The patient will not have frothy drainage, dizziness, or metallic-appearing tympanic membrane from cerumen.

DIF: Remembering (Knowledge) REF: Page 650 OBJ: 29-10

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

6. An older adult patient reports ringing in the ears. What additional data should the nurse gather to help determine the cause of the patients problem?

a.

History of ear surgery

b.

Use of prescription medications

c.

Exercise and sleep patterns

d.

Nutritional status, especially protein intake

ANS: B

Tinnitus can be a result of damage to inner structures caused by the toxic effect of certain drugs. The other assessment findings are not as important for this problem.

DIF: Applying (Application) REF: N/A OBJ: 29-10

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

7. An older patient with presbycusis has been advised to purchase a hearing aid and asks about its function and use. Which information is most accurate to give the patient about the function of hearing aids?

a.

Hearing aids amplify sound but do not improve the ability to hear.

b.

Hearing aids improve the ability to hear by intensifying the duration of sound waves.

c.

Hearing aids control the input of sound waves to eliminate extraneous noise.

d.

Hearing aids intensify sound waves and improve the ability to hear.

ANS: A

Hearing aids amplify sound but do not improve the ability to hear. The other statements are not accurate regarding hearing aids.

DIF: Understanding (Comprehension) REF: Page 654 OBJ: 29-11

TOP: Teaching-Learning MSC: Physiologic Integrity

8. An older adults chart documents that she has been diagnosed with macular dysequilibrium. Based on an understanding of this condition and the resulting vertigo, the nurse suggests that the patient:

a.

turn her head very slowly when looking from right to left.

b.

dangle her legs at the bedside before getting out of bed.

c.

use the wall for stabilization when ambulating in the hallway.

d.

be careful to be seated when flexing or hyperextending her neck.

ANS: B

Macular disequilibrium is vertigo precipitated by a change of head position in relation to the direction of gravitational force (e.g., severe dizziness when rising from bed). Dangling at the bedside and changing positions slowly will decrease the chance of injury. The other interventions do not relate to this disorder.

DIF: Understanding (Comprehension) REF: Page 655 OBJ: 29-7

TOP: Teaching-Learning MSC: Safe Effective Care Environment

9. A 96-year-old patient reports symptoms of xerostomia. The nurse attempts to minimize the effects of the condition by:

a.

providing appropriate fluids with the patients meals.

b.

cutting the patients meat into small bite-sized pieces.

c.

elevating the head of the patients bed at mealtimes.

d.

assisting the patient with oral care before each meal.

ANS: A

Xerostomia, commonly referred to as dry mouth, is a subjective sensation of abnormal oral dryness. Reduced salivary flow is a common complaint of older adults. Dry mouth in the older adult can lead to an increased risk of serious respiratory infection, impaired nutritional status, and reduced ability to communicate. Offering appropriate fluids with meals will assist with proper nutrition. The other options will not provide relief for this condition.

DIF: Applying (Application) REF: N/A OBJ: 29-8

TOP: Nursing Process: Implementation MSC: Physiologic Integrity

10. The preferred way for the nurse to communicate with a 72-year-old hearing-impaired patient is to:

a.

speak loudly into the patients unaffected ear.

b.

exaggerate the form of each word.

c.

provide all communication in written form.

d.

speak clearly and directly, facing the person.

ANS: D

Interventions for the patient with a hearing impairment focus on aural rehabilitation and facilitation of communication. Patients should be spoken to using a clear voice and face to face, which gives the patient an unobstructed view of the speakers face and lips. The other techniques are not as helpful.

DIF: Remembering (Knowledge) REF: Page 653 OBJ: 29-11

TOP: Nursing Process: Implementation MSC: Physiologic Integrity

11. A patient in a nursing home is confused, nonverbal, but pleasant. The nurse notes the patient has suddenly become agitated and is screaming and scratching at the eyes. While the nurse is examining the patient, the patient vomits. What action by the nurse is best?

a.

Consult the provider about an ophthalmologic exam.

b.

Sedate the patient so she wont injure herself.

c.

Place mitts on the patients hands to avoid scratches.

d.

Give the patient a prn medication for pain.

ANS: A

The patient could be having an episode of acute angle closure glaucoma, manifested by severe pain, nausea and vomiting, and visual disturbances. Because the patient is nonverbal, the nurse must assess for pain with behavioral changes. The nurse should contact the provider about obtaining an ophthalmologic exam to determine if the patient has glaucoma. The other interventions will not help determine the cause of the problem. The nurse should attempt to discover the source of the behavior, not just try to control it.

DIF: Analyzing (Analysis) REF: N/A OBJ: 29-2

TOP: Communication and Documentation MSC: Physiologic Integrity

12. A patient has been admitted to the postanesthesia care unit after a trabeculectomy. What assessment takes priority?

a.

Airway

b.

Pain

c.

Eye patch

d.

Blood pressure

ANS: A

Airway always comes first when prioritizing care.

DIF: Applying (Application) REF: N/A OBJ: 29-2

TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment

13. A patient had cataract surgery without a lens implant. What teaching point is most important?

a.

Keep your follow-up appointment with the surgeon.

b.

Instill your eyedrops just like we have practiced.

c.

Do not drive and be careful going up or down stairs.

d.

Take acetaminophen (Tylenol) for pain.

ANS: C

If cataract surgery was performed without a lens implant, the patient will wear glasses or contact lenses but will have a decrease in depth perception. The patient should not drive and should use extra caution negotiating stairs. The other instructions are appropriate for any patient having cataract surgery.

DIF: Applying (Application) REF: N/A OBJ: 29-2

TOP: Teaching-Learning MSC: Safe Effective Care Environment

14. A patient has Mnire disease. What statement by the patient indicates a good ability to manage the condition?

a.

Because its from dehydration, I can increase salt in my food.

b.

There are no medications, so I just have to learn to live with it.

c.

If I get dizzy I should lie down immediately and hold my head still.

d.

Because I have asthma, I cannot take any medications for Mnire disease.

ANS: C

If the patient gets dizzy, he or she should lie down and hold the head still. A low-salt diet may help with fluid retention in the ear. There are several medications for Menire disease, but because of the anticholinergic properties of some of them, people with asthma, glaucoma, or BPH should be monitored closely.

DIF: Evaluating (Evaluation) REF: N/A OBJ: 29-7

TOP: Nursing Process: Evaluation MSC: Health Promotion

15. A patient had a chemical splash into the eye at work. What action by the occupational health nurse takes priority?

a.

Begin flushing the patients eye with cool water.

b.

Call emergency medical services.

c.

Ask about the patients tetanus status.

d.

Tape the eye closed to prevent injury.

ANS: A

The nurse should begin flushing the eye immediately. While the eye is being irrigated, the nurse can call 9-1-1 and inquire about the patients last tetanus shot. The eye should not be taped shut.

DIF: Applying (Application) REF: N/A OBJ: 29-8

TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment

16. A patient with glaucoma is on timolol (Timoptic). The patient also takes metoprolol (Toprol) for hypertension. The patient reports to the clinic nurse that the eyedrops Make me dizzy. What assessment by the nurse is most appropriate?

a.

Assess the patients eyedrop instillation technique.

b.

Determine how long the patient has been on the drops.

c.

Assess the patients gait and balance while walking.

d.

Ask the patient if breakfast is eaten prior to applying the eyedrops.

ANS: A

The patient should be using punctal occlusion (closing the lacrimal duct) when instilling these eyedrops to avoid a cumulative, systemic effect from the combination of both beta-blockers. The nurse can assess the other factors as well, but this is the most likely cause of the dizziness.

DIF: Analyzing (Analysis) REF: N/A OBJ: 29-5

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

MULTIPLE RESPONSE

1. When assessing the patients vision, the nurse should understand that older adults may report common aging changes, including which of the following? (Select all that apply.)

a.

My eyelids droop so unattractively.

b.

The whites on my eyes seem a bit yellow.

c.

The vision in my right eye seems blurry.

d.

Ive started to use over-the-counter eye moisturizing drops.

e.

I have noticed the night driving has become more difficult.

ANS: A, B, D, E

The eyelids lose tone and become lax, which may result in ptosis of the eyelids, redundancy of the skin of the eyelids, and malposition of the eyelids. The conjunctiva thins and yellows in appearance. In addition, this membrane may become dry because of the diminished quantity and quality of tear production. Peripheral vision decreases, night vision diminishes, and sensitivity to glare increases.

DIF: Analysis (Analyze) REF: N/A

TOP: Nursing Process: Assessment| Neuromuscular MSC: Physiologic Integrity

2. An older adult diagnosed with Mnire disease is prescribed meclizine (Antivert) and hydrochlorothiazide (HCTZ). The nurses educational instructions include which of the following? (Select all that apply.)

a.

The need to avoid alcoholic beverages

b.

Instructions to take the medication with food

c.

Symptoms of electrolyte imbalances

d.

That drowsiness is a common side effect

e.

Stopping the medication if chest pain occurs

ANS: A, C, D

Meclizine may cause drowsiness; patients should be instructed to avoid alcoholic beverages while taking this drug. A patient on a diuretic such as hydrochlorothiazide (HCTZ) needs to be monitored for evidence of fluid or electrolyte imbalances.

DIF: Application (Apply) REF: N/A

TOP: Nursing Process: Implementation| Drug-Related Responses

MSC: Safe and Effective Care Environment

3. Which of the following are appropriate steps to take when removing cerumen from an older persons ear? (Select all that apply.)

a.

Instill a softening agent first.

b.

Use hot water and hydrogen peroxide.

c.

Use a Waterpik inserted just inside the meatus.

d.

Have the patient lean backward.

e.

Drain water by having the patient lean forward toward the affected side.

ANS: A, C, E

The nurse instills a softening agent and uses warm (not hot) water mixed with hydrogen peroxide or saline to irrigate the ear. A Waterpik or other irrigating equipment is used and is inserted just inside the meatus so the tip is still visible. Tip the patients head toward the side being irrigated. When draining, the patient can lean forward and toward the affected side.

DIF: Remembering (Knowledge) REF: Page 650-1 OBJ: 29-6

TOP: Nursing Process: Implementation MSC: Physiologic Integrity

4. A nurse is assessing a patient who reports moderate tinnitus. The nurse should assess the patient for which of the following? (Select all that apply.)

a.

Use of ibuprofen (Motrin)

b.

History of excessive cerumen

c.

Drinking carbonated beverages

d.

History of frequent headaches

e.

Presence of hypertension

ANS: A, B, D, E

Beverages with caffeine are assessed; the patient may be drinking decaffeinated cola products. The other assessments are appropriate.

DIF: Remembering (Knowledge) REF: Page 651-2 OBJ: 29-10

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

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