Exam 49: Sensory Alterations

The nurse is caring for a patient who is having difficulty understanding the written and spoken word. Which type of aphasia will the nurse report to the oncoming shift?

The nurse is using the Snellen chart. Which patient is the nurse assessing?

A nurse is teaching a patient about vision. In which order will the nurse describe the pathway for vision, beginning with the first structure? 1) Lens 2) Pupil 3) Retina 4) Cornea 5) Optic nerve

A home care nurse is inspecting a patient's house for safety issues. Which findings will cause the nurse to address the safety problems? (Select all that apply.)

During an assessment of a patient, the nurse finds the patient experiences vertigo. Which sensory deficit will the nurse assess further?

The nurse is caring for a patient in acute respiratory distress. The patient has multiple monitoring systems on that constantly beep and make noise. The patient is becoming agitated and frustrated over the inability to sleep. Which action by the nurse is most appropriate for this patient?

The nurse is caring for a patient who is taking gentamicin for an infection. Which assessment is a priority?

A nurse is caring for a patient with a right hemisphere stroke and partial paralysis. Which action by the nursing assistive personnel (NAP) will cause the nurse to praise the NAP?

A nurse is assessing cognitive functioning of a patient. Which action will the nurse take?

A nurse is caring for a patient who recently had a stroke and is going to be discharged at the end of the week. The nurse notices that the patient is having difficulty with communication and becomes tearful at times. Which intervention will the nurse include in the patient's plan of care?

A nurse is working to prevent blindness. Which preventive action is a $\bold{priority}$ ?

A nurse is administering a vaccine to a child who is visually impaired. After the needle enters the arm, the child says, "Ow, that was sharp!" How will the nurse interpret the finding when the child said that it was sharp?

A nurse is establishing a relationship with the patient who is severely visually impaired and is teaching the patient how to contact the nurse for assistance. Which action will the nurse take?

The nurse is caring for a patient who is a well-known surgeon at the hospital. The nurse notices the patient becoming more agitated and withdrawn with each group of surgeon visitors. The nurse and patient agree to place a "Do not disturb" sign on the door. A few hours later, the nurse notices a surgeon who is not involved in the patient's care attempting to enter the room. Which response by the nurse is most appropriate?

A nurse is describing the transmission of sound to a patient. In which order will the nurse list the pathway of sound, beginning with the first structure 1) Eardrum 2) Perilymph 3) Oval window 4) Bony ossicles 5) Eighth cranial nerve?

The home health nurse is caring for a patient with tactile and visual deficits. The nurse is concerned about injury related to inability to feel harmful stimuli and teaches the patient safety strategies to maintain independence. Which action by the patient indicates successful learning?

A patient has both hearing and visual sensory impairments. Which psychological nursing diagnosis will the nurse add to the care plan?

A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?

The nurse is caring for a patient with conductive hearing loss resulting from prolonged cerumen impaction. Which intervention by the nurse is most important in establishing effective communication with the patient?

The nurse is caring for a patient who is recovering from a traumatic brain injury and frequently becomes disoriented to everything except location. Which nursing intervention will the nurse add to the care plan to reduce confusion?