ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 45 : Sensory Functioning Questions
Question 1 of 5
A nurse is caring for a patient with a traumatic spinal cord injury that resulted in paraplegia (paralysis) and sensory loss from the waist down. When obtaining data about this patient, what component of sensory function does the nurse plan to assess?
Correct Answer: A
Rationale: Trauma to the spinal cord can cause both motor and sensory loss, interfering with transmission of tactile stimuli. Although the other options may be assessed, they do not relate to the spinal cord injury.
Question 2 of 5
A school nurse is performing vision screenings on middle-school children. The nurse notes a student squinting and that their visual acuity using a Snellen's eye chart is 20/160. When questioned, the student states their grades have dropped, and they are having difficulty completing work on time. What is the best recommendation for the nurse to make to the student's guardian(s)?
Correct Answer: D
Rationale: Visual acuity of 20/160 indicates myopia; this student sees at 20 feet what a person with normal vision can see at 160 feet. The impaired vision is interfering with their academic performance, and further assessment by an eye care professional is indicated.
Question 3 of 5
A nurse is caring for a patient with a severe hearing deficit who reads lips and uses sign language. Which nursing intervention would best prevent sensory alterations for this patient?
Correct Answer: C
Rationale: Providing opportunities for the patient to socialize builds on their strength of being able to lip-read and helps prevent sensory deprivation from hearing loss.
Question 4 of 5
In a group home where most residents have varying degrees of visual or hearing impairments and some are periodically confused, what nursing action is essential?
Correct Answer: A
Rationale: Safety is a basic physiologic need that must be met before higher-level needs such as love and belonging, self-esteem, and self-actualization can be met.
Question 5 of 5
A visiting nurse conducts a visit for an 11-month-old infant. The nurse finds the infant lying on the floor, rocking back and forth with a flat expression, and few vocalizations. Which nursing action would be appropriate at this time?
Correct Answer: A
Rationale: Using the first step of the nursing process, assessment, the nurse determines if the types of stimulation given by the infant's parents validate that they understand the education provided at the parenting classes. The grandmother's reduced vision would not impact the child's speech. While the infant's development is not progressing, accusing the parents of negligence is premature.