Chapter 31: The Child with a Sensory Alteration My Nursing Test Banks

Chapter 31: The Child with a Sensory Alteration

Test Bank

MULTIPLE CHOICE

1. A child tells the school nurse that he cant see things at a distance very clearly but he can read up close fine. The nurse knows that the refractive disorder causing the ability to see distant objects less clearly than those close up is termed:

a.

hyphema.

b.

astigmatism.

c.

amblyopia.

d.

myopia.

ANS: D

Myopic patients have the ability to see near objects more clearly than those at a distance; it is caused by the image focusing beyond the retina. Hyphema includes hemorrhage in the anterior chamber and is not a refractive disorder. Astigmatism is caused by an abnormal curvature of the cornea or lens. Amblyopia is a problem of reduced visual acuity not correctable by refraction.

DIF: Cognitive Level: Comprehension REF: p. 819

OBJ: Nursing Process Step: Evaluation MSC: Health Promotion and Maintenance

2. The parents of a child needing glasses ask the nurse when can we consider contact lenses for our child? The nurse should respond to this question relating that contact lenses should be prescribed for a child who is:

a.

at least 12 years of age.

b.

able to read all the written information and instructions.

c.

able to independently care for the lenses in a responsible manner.

d.

confident that she really wants contact lenses.

ANS: C

The child must be able to care for the lenses independently. Serious eye damage can occur with irresponsible use of contact lenses; confidence and wanting do not equal responsibility. Chronological age is not the major determinant. A responsible 10-year-old child might be permitted to wear contact lenses, but the ability to read does not indicate understanding of the instructions.

DIF: Cognitive Level: Application REF: p. 820

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

3. Which statement best describes how a cataract affects a childs vision?

a.

It increases intraocular pressure.

b.

It alters the ability to distinguish between colors.

c.

It causes double vision.

d.

It prevents a clear image from forming on the retina.

ANS: D

A cataract is an opacity of the lens or loss of transparency of the lens and usually does not cause double vision. Coughing, straining, or vomiting can increase intraocular pressure postoperatively. Nystagmus and strabismus are clinical signs of a cataract. Color deficiency is not a sign.

DIF: Cognitive Level: Knowledge REF: p. 822

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

4. Which statement about conjunctivitis made by a parent would indicate that further teaching is needed?

a.

Ill have separate towels and washcloths for each family member.

b.

Ill notify my doctor if the eye gets redder or the drainage increases.

c.

When the eye drainage improves, well stop giving the antibiotic ointment.

d.

After taking the antibiotic for 24 hours, my child can return to school.

ANS: C

The antibiotic should be continued for the full prescription and the child should be kept home from school or day care until he receives the antibiotic for 24 hours. Maintaining separate towels and washcloths will prevent the other family members from acquiring the infection. If the infection proliferates, the physician should be contacted.

DIF: Cognitive Level: Application REF: p. 824

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

5. Which teaching guideline would help prevent eye injuries during sports and play activities?

a.

Restrict helmet use to those who wear eye glasses or contact lenses.

b.

Discourage the use of goggles with helmets.

c.

Wear eye protection when participating in high-risk sports such as paintball.

d.

Wear a face mask when playing any sport or playing roughly.

ANS: C

High-risk sports such as paintball can cause penetrating eye injuries. Eye protection should be worn. All children who play games should be protected by the appropriate headgear with goggles and helmets being used concurrently. A face mask does not prevent damage to the childs head.

DIF: Cognitive Level: Comprehension REF: p. 826

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

6. A nurse is admitting a child with a chemical burn to the eye. The nurse questions the EMS personnel about initial care at the time of the injury. The nurse understands that initial care of the child with a chemical burn to the eye(s) is focused on:

a.

irrigation of the affected eye(s).

b.

application of topical steroids.

c.

administration of an analgesic.

d.

administration of medication to constrict the pupils.

ANS: A

Chemical eye burns are an ocular emergency and are best managed by immediate irrigation of the eye(s) with water or normal saline solution. Topical steroids usually are applied after irrigation. Caring for a frightened child is very difficult. Pain medication may help the child cope with the situation, but the initial care is irrigation. Further treatment may include the use of medications to dilate the pupils to decrease the risk of adhesions.

DIF: Cognitive Level: Comprehension REF: p. 826

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

7. Which type of hearing loss in a child is usually irreversible?

a.

Conductive

b.

Sensorineural

c.

Central

d.

Nonconductive

ANS: B

When hearing loss is caused by malformations, auditory nerve damage, or infection the loss is usually permanent. Damage caused by inflammation or obstruction usually causes a temporary and reversible hearing loss. A central type of hearing loss usually causes difficulties in differentiating sounds and problems with auditory memory and it is reversible. Nonconductive hearing loss is commonly reversed with surgery or medication.

DIF: Cognitive Level: Comprehension REF: p. 827

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

8. On the second postoperative day following an eye surgery, the child has puffy eyes, increased drainage, and tearing. Which is the most applicable nursing diagnosis?

a.

Risk for infection related to the surgical procedure

b.

Risk for injury related to increased intraocular pressure

c.

Disturbed sensory perception (visual) related to the surgical procedure

d.

Acute pain related to recent surgical intervention

ANS: A

Any surgical procedure leaves the patient vulnerable to infection. There is no datum in the scenario to validate increased intraocular pressure or to support a diagnosis for disturbed sensory perception (visual) related to a surgical procedure. Usually eye surgeries are relatively painless.

DIF: Cognitive Level: Application REF: p. 823

OBJ: Nursing Process Step: Nursing Diagnosis MSC: Physiological Integrity

9. Parents of a 4-year-old child are concerned because he continues to stutter. Which nursing intervention is correct?

a.

Remind the parents that stuttering is normal in children younger than 10 years.

b.

Ask the parents to have a speech evaluation performed if the stuttering continues beyond the age of 5 years.

c.

Reinforce the fact that this common speech defect requires no treatment.

d.

Tell the parents that speech problems are most treatable during the childs teen years.

ANS: B

If stuttering persists after 5 years of age, the child should be seen by the physician and referred to a speech therapist. Stuttering is not normal after the age of 5 years. Early diagnosis, intervention, and treatment are critical in assisting the child to develop as normally as possible and to correct the speech disorder.

DIF: Cognitive Level: Application REF: p. 829

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

10. A 13-year-old adolescent is diagnosed with a sensory alteration and is scheduled for diagnostic tests. She asks the nurse to tell her the truth about the tests. Which response is the best?

a.

Dont worry about anything. Were here to take good care of you.

b.

Ask your parents. They have talked with the physicians.

c.

Most of the tests are painless and noninvasive.

d.

Trust the doctors. They know what is best for you.

ANS: C

The nurse should be knowledgeable and honest in answering questions about procedures. The nurse should not provide false reassurance as it blocks communication. A 13-year-old adolescent is old enough to comprehend explanations and is entitled to receive the pertinent information regarding her health. Patients, especially teenagers, do not appreciate healthcare providers who do not treat them with honesty and respect.

DIF: Cognitive Level: Application REF: pp. 827-828

OBJ: Nursing Process Step: Implementation MSC: Psychosocial Integrity

11. Teaching parents about the use and application of an eye patch to treat strabismus should include which information?

a.

Check the patched eye four times a day by removing the patch and replacing it after inspection.

b.

Apply the patch directly to the face.

c.

Sometimes patching alone will straighten the eye.

d.

Negotiate with the child for the number of hours per day that the patch is to be worn.

ANS: B

The patch should be securely applied to the face. Parents often apply the eye patch to the childs eyeglasses. Once the patch is in place, it should remain there for the prescribed number of hours. Patching alone will not straighten the eye. The amount of time the child wears the eye patch is not negotiable. Parents should learn strategies for dealing with resistant behaviors.

DIF: Cognitive Level: Comprehension REF: p. 820

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

12. The correct position for the postoperative child who has had a cataract removed from the right eye is the _____ position.

a.

supine

b.

prone

c.

knee-chest

d.

right lateral Sims

ANS: A

To prevent edema and pressure on the operative site, the nurse should elevate the head of the bed slightly and avoid placing the child in a dependent position. The prone position is a dependent position, which is contraindicated after cataract surgery. The knee-chest position is contraindicated after cataract surgery. The right lateral Sims position would increase pressure on the operative site.

DIF: Cognitive Level: Application REF: p. 822

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

13. Which manifestation in a 5-month-old child could indicate visual problems?

a.

Lack of binocularity

b.

Visual acuity of 20/50

c.

Strabismus

d.

Hyperopia

ANS: C

Strabismus is normal in the young infant but should not be present after 3 months of age. Binocularity, the ability to fixate on one visual field with both eyes, is not present at birth but is established by 6 months of age. Visual acuity by 4 months of age is between 20/50 and 20/80. Hyperopia, or farsightedness, is normal until about 7 years of age.

DIF: Cognitive Level: Comprehension REF: p. 818

OBJ: Nursing Process Step: Assessment MSC: Health Promotion and Maintenance

14. The nurse should teach parents that the results of untreated amblyopia in the child may result in:

a.

impaired depth perception.

b.

strabismus.

c.

color deficiency.

d.

ptosis.

ANS: A

Untreated amblyopia causes the child to lose binocular vision, which may impair depth perception. Amblyopia, or decreased vision in the deviated eye, results from strabismus. Color deficiency and ptosis, or dropping of the eyelid, are not the result of untreated amblyopia.

DIF: Cognitive Level: Application REF: p. 820

OBJ: Nursing Process Step: Implementation

MSC: Health Promotion and Maintenance

15. The teaching plan for the parents of a 3-year-old child with amblyopia should include which instructions?

a.

Apply a patch to the childs eyeglass lenses.

b.

Apply a patch only during waking hours.

c.

Apply a patch over the bad eye to strengthen it.

d.

Cover the good eye completely with a patch.

ANS: D

The good eye is patched to force the child to use the bad eye, thus strengthening the muscles. The patch should always be applied directly to the childs face, not to eyeglasses, and should be left in place even when the child is sleeping. Covering the bad eye will not contribute to strengthening it. The good eye should be patched.

DIF: Cognitive Level: Application REF: p. 820

OBJ: Nursing Process Step: Planning MSC: Physiological Integrity

16. The teaching plan for a 7-year-old boy with color deficiency should include which instruction?

a.

Buy only one color of clothing to ensure the childs ability to match items himself.

b.

Patching the weaker eye will improve his color vision.

c.

Teach him an alternate way to distinguish between the colors of traffic signals.

d.

Botulism toxin drops will need to be administered every 2 months to improve color vision.

ANS: C

The child who cannot distinguish colors of warning signals must be taught an alternative way to identify these signals. Clothes may be labeled or organized so the child can identify them. They do not have to be purchased in only one color. There is no cure, treatment, or correction for color blindness. Because the eye is not weak, patching will not correct the color deficiency. The child can be taught adaptive measures to compensate for the condition.

DIF: Cognitive Level: Application REF: p. 818

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

17. A 2-year-old girl has excessive tearing and corneal haziness. The nurse knows that these symptoms may indicate:

a.

viral conjunctivitis.

b.

paralytic strabismus.

c.

congenital cataract.

d.

infantile glaucoma.

ANS: D

Excessive tearing and corneal haziness are indicative of glaucoma. Because the child is younger than 3 years of age, it would be classified as infantile. Discharge is noted with conjunctivitis. Corneal haziness is not a symptom of conjunctivitis. Paralytic strabismus is caused by weakness or paralysis of one or more of the extraocular muscles. Neither tearing nor corneal haziness is a symptom of paralytic strabismus. Congenital cataract will cause an opacity, but not excessive tearing.

DIF: Cognitive Level: Knowledge REF: p. 821

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

18. Which should be the most significant nursing intervention in caring for a child who has just returned from eye surgery to prevent increasing intraocular pressure?

a.

Monitor for hypertension, which is a symptom of increased intraocular pressure.

b.

Prevent coughing and vomiting.

c.

Lower the head of the bed slightly and place the eye in a dependent position.

d.

Avoid use of steroids after the surgery.

ANS: B

Preventing coughing, straining, vomiting, and touching the operative site are all measures directed toward avoiding increased intraocular pressure. Hypertension is not a symptom of increased intraocular pressure. The head of the bed should be raised slightly and the eye placed in a position that is not dependent to prevent increasing intraocular pressure. Steroids, antibiotics, and mydriatics may be used after the surgery.

DIF: Cognitive Level: Application REF: p. 823

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

19. A 5-year-old girl diagnosed with chlamydial conjunctivitis should be carefully assessed for:

a.

sexual abuse.

b.

immune deficiency.

c.

congenital cataract.

d.

secondary glaucoma.

ANS: A

A diagnosis of chlamydial conjunctivitis in a nonsexually active child should signal the healthcare provider to assess the child for sexual abuse. Chlamydial conjunctivitis in a nonsexually active child is most often associated with sexual abuse; it is not related to congenital cataract or secondary glaucoma.

DIF: Cognitive Level: Application REF: p. 824

OBJ: Nursing Process Step: Assessment MSC: Psychosocial Integrity

20. Which statement made by a parent indicates understanding of the instructions on the care of a child with conjunctivitis?

a.

I should treat my other children with these eye drops to prevent the spread of the disease.

b.

My child must remain home from school until he has received 72 hours of antibiotic drops.

c.

I should avoid touching the tip of the ointment tube to my childs eye.

d.

My child may go back to wearing his contact lens 24 hours after treatment has started.

ANS: C

Care should be taken to avoid touching the tip of the ointment tube or dropper to the eye to avoid contamination of the medication. To avoid cross-contamination, medication should never be shared. The child should remain home from school until he has had 24 hours of medication. The child should not wear a contact lens until treatment is completed.

DIF: Cognitive Level: Application REF: p. 824

OBJ: Nursing Process Step: Evaluation MSC: Physiological Integrity

21. Discharge planning for an 8-year-old child with a patched eye after a corneal abrasion should include:

a.

removing the patch after 8 hours for instillation of antibiotic ointment.

b.

gently massaging the affected eye to prevent edema.

c.

instilling antibiotic ointment after patching for 24 hours.

d.

returning after 7 days of patching for reassessment.

ANS: C

With severe abrasions, the eye should be patched and left undisturbed for 24 hours. After 24 hours, treatment with antibiotic ointment is started. Massaging the affected eye will increase the size of the abrasion and should be avoided. The child should return in 24 hours for reassessment if the eye is patched.

DIF: Cognitive Level: Application REF: p. 825

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

22. A patient who has a hyphema would be at risk for development of which complication?

a.

Glaucoma

b.

Strabismus

c.

Diplopia

d.

Astigmatism

ANS: A

After hyphema, there is a risk for the development of glaucoma. Strabismus, diplopia, and astigmatism are not related to hyphema.

DIF: Cognitive Level: Comprehension REF: p. 825

OBJ: Nursing Process Step: Assessment MSC: Physiological Integrity

23. A mother brings her 18-month-old son to the pediatrician for a routine well-child visit. She is concerned about her childs speech. He has been babbling and cooing since 6 months of age but is not yet saying any words. Which response by the nurse would be the most appropriate?

a.

Dont worry, he should catch up soon. Boys are always slower at speaking than girls.

b.

The doctor will want to refer your son to an audiologist and speech pathologist.

c.

This is normal speech development for an 18-month-old child.

d.

Your son has an expressive language disorder and will need a referral for further evaluation.

ANS: B

An appropriate response is one in which the doctor refers the son to an audiologist and speech pathologist. By 18 months children should have a three-word vocabulary. Adequate hearing is essential for the development of speech. Hearing and language should be tested and a referral to an audiologist and speech pathologist is indicated. The nurse should not provide inappropriate reassurance that her son will be fine. He needs to be referred for further evaluation as this is not normal speech development for an 18-month-old child. The nurse is not qualified to offer a diagnosis to the mother of this patient on the basis of the limited information provided. Further tested and a referral are indicated for this patient.

DIF: Cognitive Level: Comprehension REF: p. 829

OBJ: Nursing Process Step: Planning MSC: Health Promotion and Maintenance

MULTIPLE RESPONSE

1. The nurse should plan which interventions when caring for a child with a visual impairment? Select all that apply.

a.

Touch the child upon entering the room before speaking.

b.

Keep items in the room in the same location.

c.

Describe the placement of the eating utensils on the meal tray.

d.

Use color examples to describe something to a child who has been blind since birth.

e.

Identify noises for the child.

ANS: B, C, E

Keep all items in the room in the same location and order. Describing how many steps away something is or the placement of eating utensils on a tray are both useful tactics. Identify noises for the child because children who are visually impaired or blind often have difficulty establishing the source of a noise. Never touch the child without identifying yourself and explaining what you plan to do. When describing objects or the environment to a child who is blind or visually impaired, use familiar terms. If the child has been blind since birth, color has no meaning.

DIF: Cognitive Level: Application REF: p. 828

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

2. The nurse should plan which interventions when caring for a child with a hearing loss? Select all that apply.

a.

Speak loudly.

b.

Speak slowly.

c.

Do not slow speech.

d.

Use visual aids.

e.

Eliminate background noise.

ANS: B, D, E

Speak clearly and at a slightly slower speed than normal. Do not speak loudly. Eliminate background noise so the child can focus on what is being said. Use visual aids to assist communication.

DIF: Cognitive Level: Application REF: p. 828

OBJ: Nursing Process Step: Implementation MSC: Physiological Integrity

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