Question 1

The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the next best action?

Accepted Answer

A)  Notify the physician. 
B)  Document the finding in the records. 
C)  Recheck the reflex after several hours. 
D)  Monitor the eye movements and pupil reactions closely. 
A)  Notify the physician. 
B)  Document the finding in the records. 
C)  Recheck the reflex after several hours. 
D)  Monitor the eye movements and pupil reactions closely. A

Question 2

The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements?

Accepted Answer

A)  "This will help us to identify your baby's risk for ear infections the first year of life." 
B)  "Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother." 
C)  "Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child." 
D)  "Imitation of sounds is the first step in language development, and it is important to identify alterations early." 
A)  "This will help us to identify your baby's risk for ear infections the first year of life." 
B)  "Hearing is important so your baby hears and responds to your voice, which makes you feel like a mother." 
C)  "Socialization skills include the need to hear in order to interpret the emotional aspect of the words that are spoken to your child." 
D)  "Imitation of sounds is the first step in language development, and it is important to identify alterations early." D

Question 3

An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following?

Accepted Answer

A)  "I will make sure that Dad always wears warm socks." 
B)  "Dad needs to wear his glasses so he can delay the onset of macular degeneration." 
C)  "I will ask the home health aide to carefully inspect Dad's feet every day when she helps him bathe." 
D)  "We will give him only warm foods, so that he doesn't burn his mouth." 
A)  "I will make sure that Dad always wears warm socks." 
B)  "Dad needs to wear his glasses so he can delay the onset of macular degeneration." 
C)  "I will ask the home health aide to carefully inspect Dad's feet every day when she helps him bathe." 
D)  "We will give him only warm foods, so that he doesn't burn his mouth." C

Question 4

A 75-year-old woman walks into the emergency department with complaints of "not feeling well." Her blood pressure is 145/95, pulse 85 beats/min, respirations 24 breaths/min, and blood sugar 300. Upon inspection, the nurse notices that the woman has an open wound on the bottom of her foot, but the patient states she is not aware of this. How should the nurse interpret these findings?

Accepted Answer

A)  Normal in the older adult 
B)  A need for the patient to be evaluated for cognitive impairment 
C)  A side effect of anti-hypertensive medication 
D)  Pathologic impairment of sensory responses 
A)  Normal in the older adult 
B)  A need for the patient to be evaluated for cognitive impairment 
C)  A side effect of anti-hypertensive medication 
D)  Pathologic impairment of sensory responses

Question 5

The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse's best action to provide recreational activities during the rehabilitation phase?

Accepted Answer

A)  Place the television to the left or right of patient's visual field. 
B)  Encourage the patient to learn braille. 
C)  Suggest use of talking books. 
D)  Provide headphones for listening to music. 
A)  Place the television to the left or right of patient's visual field. 
B)  Encourage the patient to learn braille. 
C)  Suggest use of talking books. 
D)  Provide headphones for listening to music.

Question 6

During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient's wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure?

Accepted Answer

A)  Tympanoplasty 
B)  Irrigation of the ear 
C)  Pure tone test 
D)  Otoscopic exam by a specialist 
A)  Tympanoplasty 
B)  Irrigation of the ear 
C)  Pure tone test 
D)  Otoscopic exam by a specialist

Question 7

The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction?

Accepted Answer

A)  "I will take my child to the audiologist because he doesn't seem to hear me except when I look directly at him." 
B)  "Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle." 
C)  "Making my child wear ear plugs when she goes to a rock concert may save her hearing!" 
D)  "I see now why when my child has a cold, he complains about everything tasting blah!" 
A)  "I will take my child to the audiologist because he doesn't seem to hear me except when I look directly at him." 
B)  "Both of my children have the same eye medication, which is a real bonus, because I only need to buy one bottle." 
C)  "Making my child wear ear plugs when she goes to a rock concert may save her hearing!" 
D)  "I see now why when my child has a cold, he complains about everything tasting blah!"

Question 8

An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response?

Accepted Answer

A)  "Your wife should increase the spices in your food, as the pneumonia changes your sense of smell." 
B)  "Notify your doctor immediately, because this is a concerning reaction to the medication." 
C)  "You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection." 
D)  "You should see an improvement in the next week or so. Call if this continues." 
A)  "Your wife should increase the spices in your food, as the pneumonia changes your sense of smell." 
B)  "Notify your doctor immediately, because this is a concerning reaction to the medication." 
C)  "You need to take an appetite stimulant, as your body will need good nutrition to recover from the infection." 
D)  "You should see an improvement in the next week or so. Call if this continues."

Exam 28: Sensory Perception

The nurse is examining the eyes of a newborn infant. If the nurse notes the absence of the red reflex, what is the next best action?

The nurse requests that a mother give permission for a hearing test in a newborn infant. The mother questions the importance of such a test. The nurse correctly responds with which of the following statements?

An 80-year-old patient is being discharged after he was diagnosed with diabetes mellitus and retinopathy. His daughter has been part of the discharge instruction process. Understanding of the instructions is evident when the daughter says which of the following?

The patient who had a hip replacement yesterday has a visual acuity of 20/200 after correction. What is the nurse's best action to provide recreational activities during the rehabilitation phase?

During the examination of the ear, a dark yellow substance is noted in the ear canal. The tympanic membrane is not visible. The patient's wife complains that he never hears what she says lately. These findings would suggest that the nurse prepare the patient for which procedure?

The nurse is providing health teaching to a group of mothers of school-aged children. Which statement by a mother indicates the need for additional instruction?

An adult male patient is complaining of decreased appetite. He states he just finished taking his antibiotics for an episode of pneumonia. What is the nurse's best response?

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