Online Practice Test 38

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Site Title: Kozier & Erb's Fundamentals of Nursing Book Title: Kozier & Erb's Fundamentals of Nursing Location on Site: Chapter 38 > NCLEX® Review Date/Time Submitted: July 25, 2012 at 2:50 PM (UTC/GMT)

Summary of Results 50% Correct of 10 Scored items: 5 Correct:  50% 5 Incorrect:  50% More information about scoring

1.		Clients admitted into the emergency department may experience behavior changes due to: Your Answer: Sensoristasis Correct Answer: Sensory overload
		Objective: Discuss anatomic and physiologic components of the sensory-perception process. Rationale: Sensoristasis is time of optimum arousal, not too much or too little. Sensory reception is the process of receiving internal and external data. This is partially correct, in that the client does receive data that may result in behavior changes. However, Answer 4 is a better answer in that it more directly addresses the situation presented. Stereognosis is the awareness of an object's size, shape, and texture. Nursing Process: Assessment Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
2.		While performing a history, the nurse assesses sensory perceptions such as:  Your Answer: Cranial nerves Correct Answer: Mental status
		Objective: Describe essential components in assessing a client's sensory-perception function. Rationale: Mental status is assessed while performing a history. Kinesthetic perception, deep tendon reflexes, and cranial nerves are assessed during the physical exam, not the history. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
3.		Peripheral neuropathy and paresthesias become the etiology for other nursing diagnoses. An example of such a diagnosis is: Your Answer: Risk for injury
		Objective: Develop nursing diagnoses and outcome criteria for clients with impaired sensory function. Rationale: The nurse determines what effects peripheral neuropathy will have on the client. Swallowing takes place in the posterior pharynx and esophagus. This is centrally located; unrelated to peripheral neuropathy. Fluid overload is related to excess intake relative to output, or organ failure such as heart failure, not sensory perception. It is unlikely paresthesias would cause social isolation. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
4.		A nurse promotes healthy sensory function for infants when the nurse: Your Answer: Performs a hearing screen on each newborn Correct Answer: Allows the newborn to nurse within minutes of birth
		Objective: Discuss nursing interventions to promote and maintain sensory function. Rationale: The newborn imprints the smell of the mother's milk and body. Hearing screening and Apgar assess sensory function, but do not promote function. Visitors in birth centers need to be assessed for infection to prevent the spread to newborns. Nursing Process: Planning Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
5.		Nurses can increase environmental stimuli for clients with sensory deficit by: Your Answer: Keeping the bathroom light on at night to avoid complete darkness Correct Answer: Establishing a routine identified with each meal
		Objective: Discuss nursing interventions to promote and maintain sensory function. Rationale: Regular meaningful stimuli will benefit the client. The radio can provide meaningful or meaningless stimuli. The nurse must carefully choose programming based on the client's preferences and expose the client to that programming only at appropriate times. Listening to the radio constantly can introduce meaningless stimuli that confuse the client. A 24-hour light may actually keep clients awake, leading to sleep deprivation. Safety is a priority diagnosis but is not an intervention to provide environmental stimuli. Nursing Process: Assessment Client Need: Health Promotion and Maintenance Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection
6.		A client has impaired vision. An intervention to best adapt the environment to this loss includes: Your Answer: Keeping the room pathways free of clutter
		It is easier to learn a room's path if unexpected objects are not in the way. It is too easy to trip on such clutter. Objective: Discuss nursing interventions to promote and maintain sensory function. Rationale: Interventions will focus on compensating for the loss of vision in order to optimize client independence. Initially, the nurse may need to assist the client with ambulation. Later, the nurse will need to evaluate whether this is still necessary. Clients unfamiliar with side rails may find them confusing and actually fall trying to climb over them. Regular schedules help clients orient to time, but are less likely to benefit those with vision loss. This answer may be correct, but keeping the room pathways free of clutter is the better answer. Nursing Process: Implementation Client Need: Safe, Effective Care Environment Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
7.		Which statement by a client with decreased hearing indicates a need for a sensory aid in the home? Your Answer: "I tripped over that throw rug again." Correct Answer: "I can't hear people knocking at the door."
		Objective: Discuss factors that place a client at risk for sensory disturbances. Rationale: A sensory aid will help the client compensate for hearing loss. "My eyesight is good if I wear my glasses" and "I tripped over that throw rug again" are unrelated to hearing deficit. "I can hear the radio if I turn it up high" is an example of compensation. Nursing Process: Evaluation Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.
8.		Which of the following questions would be easiest for a client with a hearing deficit to understand? Your Answer: "Water?"
		A simple, clearly spoken, one-word question is less confusing and easier to understand than more complex phrases. Objective: Develop nursing diagnoses and outcome criteria for clients with impaired sensory function. Rationale: Simple is more easily heard than complex. The more words there are in a sentence, the more likely it is that some will not be understood, causing a distortion in meaning. Nursing Process: Planning Client Need: Physiological Integrity Cognitive Level: Application Strategy: Use nursing knowledge and the process of elimination to make a selection.
9.		Which statement by a hospitalized client indicates she needs further orientation to time, place, person, or situation? Your Answer: "I'm tired of sitting in this train station."
		Objective: Identify strategies to promote and maintain orientation to person, place, time, and situation for the client with acute confusion/delirium. Rationale: Listen to clients carefully to pick up signs of disorientation and not confuse them with other causes. Comparing a hospital to a train station is an appropriate analogy for an oriented person in the hospital. A client's statement about remembering a hospital is not uncommon. Not remembering a staff member may reflect impaired memory related to organic causes, multiple caregivers, medication, or stress, yet the client asks an appropriate question to clear the memory lapse. Nursing Process: Evaluation Client Need: Psychosocial Integrity Cognitive Level: Analysis Strategy: Decide what is the best action for client and situation.
10.		Which client is most likely to experience sensory deprivation? Your Answer: A deaf 88-year-old single client with +4 edema who lives in an upstairs apartment
		Objective: Identify clinical signs and symptoms of sensory overload and deprivation. Rationale: Sensory stimulation comes from our senses, environment, and presence of meaningful data. Although the client has no sight and is unable to get out of bed, she is still capable and likely to receive sensory stimulation. She may converse with staff and other residents, feel the touch of bathing, and taste a variety of foods. There is a potential for sensory deprivation related to abandonment and the presence of anomalies. Since the child is being cared for in a special needs foster home, and attends preschool, one can reasonably assume that the child receives some stimulation. Premature infants in Neonatal Intensive Care Units often suffer from sensory overload. Nursing Process: Assessment Client Need: Physiological Integrity Cognitive Level: Analysis Strategy: Use nursing knowledge and the process of elimination to make a selection.