Chapter 55: The Child with a Sensory Alteration My Nursing Test Banks

Chapter 55: The Child with a Sensory Alteration

Test Bank

MULTIPLE CHOICE

1. An adolescent boy goes to his primary care provider complaining of difficulty with his vision. When the nurse asks the adolescent to explain what visual deficits he is experiencing, the adolescent states, I am having difficulty seeing distant objects; they are less clear than things that are close. What disorder does the nurse suspect the adolescent has?

a.

Hyphema

b.

Astigmatism

c.

Amblyopia

d.

Myopia

ANS: D

Feedback

A

Hyphema includes hemorrhage in the anterior chamber and is not a refractive disorder.

B

Astigmatism is caused by an abnormal curvature of the cornea or lens.

C

Amblyopia is a problem of reduced visual acuity not correctable by refraction.

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.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1503 | Table 55-1

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

2. A 10-year-old patient is talking to the nurse about wanting to try contact lenses instead of wearing glasses. She states that the other children at her school call her four-eyes. 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

Feedback

A

Chronologic age is not the major determinant. A responsible 10-year-old child might be permitted to wear contact lenses.

B

The ability to read does not indicate understanding of the instructions.

C

The child must be able to care for the lenses independently. Serious eye damage can occur with irresponsible use of contact lenses.

D

Confidence and wanting do not equal responsibility.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1504

OBJ: Nursing Process: Assessment MSC: Client Needs: 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

Feedback

A

Coughing, straining, or vomiting can increase intraocular pressure postoperatively.

B

Nystagmus and strabismus are clinical signs of a cataract. Color deficiency is not a sign.

C

A cataract usually does not cause double vision.

D

A cataract is an opacity of the lens or loss of transparency of the lens.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1506

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

4. Which statement by a parent about conjunctivitis indicates 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

Feedback

A

Maintaining separate towels and washcloths will prevent the other family members from acquiring the infection.

B

If the infection proliferates, the physician should be contacted.

C

The antibiotic should be continued for the full prescription.

D

The child should be kept home from school or day care until the child receives the antibiotic for 24 hours.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1509

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity

5. Which teaching guideline helps 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

Feedback

A

All children who play games should be protected by the appropriate headgear.

B

Goggles and helmets can and should be used concurrently.

C

High-risk sports such as paintball can cause penetrating eye injuries. Eye protection should be worn.

D

A face mask does not prevent damage to the childs head.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1511

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

6. 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

Feedback

A

Chemical eye burns are an ocular emergency and best managed by immediate irrigation of the eye(s) with water or normal saline solution.

B

Topical steroids usually are applied after irrigation.

C

Caring for a frightened child is very difficult. Pain medication may help the child cope with the situation, but the initial care is irrigation.

D

Further treatment may include the use of medications to dilate the pupils to decrease the risk of adhesions.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1511

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

7. The nurse is caring for a 2-year-old child who has a history of meningitis as an infant. The child is not speaking and does not turn the head to the sound of a rattle. Which type of hearing loss in a child is usually irreversible and may have resulted from a previous infection with meningitis?

a.

Conductive

b.

Sensorineural

c.

Central

d.

Mixed

ANS: B

Feedback

A

Damage caused by inflammation or obstruction usually causes a temporary and reversible hearing loss.

B

When hearing loss is caused by malformations, auditory nerve damage, or infection, the loss is usually permanent.

C

A central type of hearing loss usually causes difficulties in differentiating sounds and problems with auditory memory, and it is reversible.

D

A combination of conductive and sensorineural loss. Conductive loss is often reversible, whereas sensorineural is permanent.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1511 | Box 55-3

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

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

a.

Risk for Infection related to surgical procedure

b.

Risk for Injury related to increased intraocular pressure

c.

Disturbed Sensory Perception (Visual) related to surgical procedure

d.

Acute Pain related to recent surgical intervention

ANS: A

Feedback

A

Any surgical procedure leaves the patient vulnerable to infection.

B

There is no data in the scenario to validate this conclusion.

C

There is no data in the scenario to support this nursing diagnosis.

D

Usually eye surgeries are relatively painless.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1508

OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity

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

a.

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

b.

Inform the parents to have a speech evaluation performed if the stuttering continues beyond age 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

Feedback

A

Stuttering is not normal after age 5 years.

B

If stuttering persists after 5 years of age, the child should be seen by the physician and referred to a speech therapist.

C

Early diagnosis and intervention are important to correct speech disorders.

D

Early diagnosis and treatment of stuttering are critical in assisting the child to develop as normally as possible.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1515

OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance

10. A 13-year-old adolescent is suspected to have a visual deficit and is scheduled for further evaluation. She asks the nurse to tell the truth about the tests. What is the nurses best response?

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 vision tests are painless and noninvasive.

d.

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

ANS: C

Feedback

A

This response is false reassurance and blocks communication.

B

A 13-year-old adolescent is old enough to comprehend explanations and is entitled to receive the pertinent information regarding her health.

C

The nurse should be knowledgeable and honest in answering questions about procedures.

D

Patients, especially teenagers, do not appreciate health care providers who do not treat them with honesty and respect.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1502

OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity

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

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

Feedback

A

Once the patch is in place, it should remain there for the prescribed number of hours.

B

The patch should be securely applied to the face. Parents often apply the eye patch to the childs eyeglasses.

C

Patching alone will not straighten the eye.

D

The amount of time the child wears the eye patch is not negotiable. Parents should learn strategies for dealing with resistant behaviors.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1505

OBJ: Nursing Process: Planning MSC: Client Needs: 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

Feedback

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.

B

The prone position is a dependent position, which is contraindicated after cataract surgery.

C

The knee-chest position is contraindicated after cataract surgery.

D

The right lateral Sims position increases pressure on the operative site.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1507

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

13. What 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

Feedback

A

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.

B

Visual acuity by 4 months of age is between 20/50 and 20/80.

C

Strabismus is normal in the young infant but should not be present after 3 months of age.

D

Hyperopia, or farsightedness, is normal until about 7 years of age.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1505

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

14. The nurse should know that the results of untreated amblyopia (lazy eye) in the child may include

a.

Impaired depth perception

b.

Strabismus

c.

Color deficiency

d.

Ptosis

ANS: A

Feedback

A

Untreated amblyopia causes the child to lose binocular vision, which may impair depth perception.

B

Amblyopia, or decreased vision in the deviated eye, can result from strabismus.

C

Color deficiency is not a result of amblyopia.

D

Ptosis, or drooping of the eyelid, is not a result of untreated amblyopia.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1504

OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance

15. The teaching plan for the parents of a 3-year-old child with amblyopia (lazy eye) should include what instruction?

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

Feedback

A

The patch should always be applied directly to the childs face, not to eyeglasses.

B

The patch should be left in place even when the child is sleeping.

C

Covering the bad eye will not contribute to strengthening it. The good eye should be patched.

D

The good eye is patched to force the child to use the bad eye, thus strengthening the muscles.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1504

OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity

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

Feedback

A

Clothes may be labeled or organized so the child can identify them. They do not have to be purchased only in one color.

B

There is no cure for color blindness. Because the eye is not weak, patching will not correct the color deficiency.

C

The child who cannot distinguish colors of warning signals must be taught an alternative way to identify these signals.

D

Color deficiency cannot be treated or corrected. The child can be taught adaptive measures to compensate for the condition.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1503

OBJ: Nursing Process: Planning MSC: Client Needs: 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

Feedback

A

Discharge is noted with conjunctivitis. Corneal haziness is not a symptom of conjunctivitis.

B

Paralytic strabismus is caused by weakness or paralysis of one or more the extraocular muscles. Neither tearing nor corneal haziness are symptoms of paralytic strabismus.

C

A congenital cataract will cause an opacity, but not excessive tearing.

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.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1506

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity

18. What is the most significant nursing intervention to prevent increasing intraocular pressure when caring for a child who has just returned from cataract eye surgery?

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

Feedback

A

Hypertension is not a symptom of increased intraocular pressure.

B

Preventing coughing, straining, vomiting, and touching the operative site are all measures directed toward avoiding increased intraocular pressure.

C

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.

D

Steroids, antibiotics, and mydriatics may be used after the surgery.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1508

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic 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

Feedback

A

A diagnosis of chlamydial conjunctivitis in a nonsexually active child should signal the health care provider to assess the child for sexual abuse.

B

Chlamydial conjunctivitis in a nonsexually active child is most often associated with sexual abuse.

C

Chlamydial conjunctivitis is not related to congenital cataract.

D

Chlamydial conjunctivitis is not related to secondary glaucoma.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1508

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

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

a.

I should treat my other children with these eyedrops to prevent 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 lenses 24 hours after treatment has started.

ANS: C

Feedback

A

To avoid cross-contamination, medication should never be shared.

B

The child should remain home from school until 24 hours after receiving medication.

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.

D

The child should not wear contact lenses until treatment is completed.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1509

OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic 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.

Keeping the patch in place for 24 hours

d.

Returning after 7 days of patching for reassessment

ANS: C

Feedback

A

The patch should be left undisturbed for 24 hours.

B

Massaging the affected eye will increase the size of the abrasion and should be avoided. The child should also be taught not to rub the affected eye.

C

With severe abrasions, the eye should be patched and left undisturbed for 24 hours. After 24 hours, treatment with antibiotic ointment is started.

D

The child should return in 24 hours for reassessment if the eye is patched.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1510

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

22. A patient who has a hyphema is at risk for developing

a.

Glaucoma

b.

Strabismus

c.

Diplopia

d.

Astigmatism

ANS: A

Feedback

A

After hyphema, there is a risk for the development of glaucoma.

B

Strabismus is not related to hyphema.

C

Diplopia is not related to hyphema.

D

Astigmatism is not related to hyphema.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1510

OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic 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 is 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

Feedback

A

This is offering the parent inappropriate reassurance that her son will be fine. He needs to be referred for further evaluation.

B

This is an appropriate response. 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.

C

This is not normal speech development for an 18-month-old child.

D

The nurse is not qualified to offer a diagnosis to the mother of this patient on the basis of the limited information provided. Further testing and a referral are indicated for this patient.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1514

OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance

24. The most common type of hearing loss, which results from interference of transmission of sound to the middle ear, is called

a.

Conductive

b.

Sensorineural

c.

Mixed conductive-sensorineural

d.

Central auditory imperceptive

ANS: A

Feedback

A

Conductive or middle ear hearing loss is the most common type. It results from interference of transmission of sound to the middle ear, most often from recurrent otitis media.

B

Sensorineural is a less common type of hearing loss.

C

Mixed conductive-sensorineural is a less common type of hearing loss.

D

Central auditory imperceptive is a less common type of hearing loss.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1511 | Box 55-3

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

25. The nurse should suspect a hearing impairment in an infant who demonstrates

a.

Absence of the Moro reflex

b.

Cessation of babbling at age 7 months

c.

Lack of eye contact when being spoken to

d.

Lack of gesturing to indicate wants after age 15 months

ANS: B

Feedback

A

Failure to develop intelligible speech is not considered a problem by 12 months. This would be considered a problem at 24 months.

B

Infants who are deaf babble like hearing infants until approximately 5-6 months of age, at which time babbling is noted to cease.

C

The lack of a startle reflex indicates a problem with hearing.

D

The child with hearing impairment uses gestures rather than vocalizations to express desires at this age.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1513

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

26. A nurse suspects possible visual impairment in a child who displays

a.

Excessive tearing of the eyes

b.

Rapid lateral movement of the eyes

c.

Delay in speech development

d.

Lack of interest in casual conversation with peers

ANS: A

Feedback

A

Excessive tearing of the eyes, especially one accompanied by pain and itching, is a clinical manifestation of potential vision problems.

B

Rapid lateral eye movement is not associated with visual impairment.

C

A delay in speech development is not associated with visual impairment.

D

Lack of interest in casual conversation is not associated with visual impairment.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1503 | Box 55-1

OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity

27. The school nurse is caring for a child with a penetrating eye injury. Emergency treatment includes

a.

Applying a regular eye patch

b.

Applying a Fox shield to the affected eye and any type of patch to the other eye

c.

Applying ice until the physician is seen

d.

Irrigating the eye copiously with a sterile saline solution

ANS: B

Feedback

A

Applying an eye patch may cause more damage to the eye.

B

The nurses role in a penetrating eye injury is to prevent further injury to the eye. A Fox shield (if available) should be applied to the injured eye, and a regular eye patch to the other eye to prevent bilateral movement.

C

Applying ice may cause more damage to the eye.

D

Irrigating the eye may cause more damage to the eye.

PTS: 1 DIF: Cognitive Level: Comprehension REF: p. 1510

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

MULTIPLE RESPONSE

1. Which interventions should the nurse plan 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

Feedback

Correct

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.

Incorrect

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.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1511

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

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

a.

Speak loudly.

b.

Speak slowly.

c.

Have the childs full attention.

d.

Use visual aids.

e.

Eliminate background noise.

ANS: B, C, D, E

Feedback

Correct

Speak clearly and at a slightly slower speed than normal. Eliminate background noise so the child can focus on what is being said. Use visual aids to assist communication. Look directly at the child and have the childs full attention before speaking.

Incorrect

Do not speak loudly.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1514

OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity

COMPLETION

1. Adequate hearing depends on intact auditory structures and quality of sound. Failure to hear at 16 to 25 dB would be categorized as a __________ hearing loss.

ANS:

slight

Normal hearing ranges from 10 to +15 dB at a variety of frequencies. Hearing loss is categorized as follows:

Slight; failure to hear at 16 to 25 dB

Mild; failure to hear at 26 to 40 dB

Moderate; failure to hear at 41 to 55 dB

Moderately severe; failure to hear at 56 to 70 dB

Severe; failure to hear at 71 to 90 dB

Profound; failure to hear at more than 90 dB

PTS: 1 DIF: Cognitive Level: Knowledge REF: p. 1512

OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

TRUE/FALSE

1. The nurse is preparing new parents for discharge home with their well newborn. The nurse explains that the newborn cannot be discharged until the mandatory hearing screening is performed. Is this statement true or false?

ANS: T

At the recommendation of The Joint Commission on Infant Screening, most U.S. states and Canada have implemented mandatory infant hearing screening programs. As part of this program all newborns are screened before hospital discharge.

PTS: 1 DIF: Cognitive Level: Application REF: p. 1514

OBJ: Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

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