Questions With Complete Solutions
/. A nurse is assessing a client whose family is concerned that the client has developed
dementia. Which of the following findings should the nurse identify as a manifestation of
dementia?
- Rapid-onset memory loss
- Hyperglycemia
- Hypervigilance
- Difficulty problem solving
Difficulty with problem-solving is an expected manifestation of dementia. Dementia is
non-reversible, but the nurse can help the family develop strategies to manage the
client's condition.
/.A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed
nurse. Which of the following statements should the charge nurse make?
- "SPD occurs when a client's brain is unable to process rapidly occurring multiple
stimuli."
- "SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their
skin."
- "A client is diagnosed with SPD if they experience significant decrease in stimuli."
- "A client who has SPD has a deficit in the function of one or more of their five senses."
SPD is a sensory disorder in which a client experiences a hypersensitive response to
normal stimuli, such as the sound of a television, or the feel of fabric on their skin.
/.A nurse is caring for a client who has hearing loss. Which of the following actions
should the nurse use to enhance communication with the client? SATA
- Provide the client with large print materials.
- Ensure the client wears their hearing aids.
- Use a sign language interpreter.
- Communicate using paper and pen.
- Face the client when speaking. - Answer-- Ensure the client wears their hearing aids.
- Use a sign language interpreter.
- Communicate using paper and pen.
- Face the client when speaking.
/.A nurse is teaching a group of older adult clients about the sensory system. The nurse
should include that the aging process is most likely to cause which of the following
changes?
, - Decreased sense of touch
- Hearing loss
- Impaired ability to smell
- Reduced taste
Hearing and vision are the two most commonly affected senses with aging.
/.A nurse is caring for a client who states, "My doctor said I should have and EMG
(electromyograph). What is that?" Which fo the following responses should the nurse
make?
- "It is a test that determines if there is a loss of the ability to smell."
- "It is a test that measures the response of the eardrum to various sounds."
- "It is a test that determines if there is nerve damage affecting a muscle."
- "It is a test that is performed to diagnose damage to the retina of the eye."
An EMG, or electromyography, is performed to determine if there is damage to the
nerves leading to the muscles. During an EMG, very small needles are inserted into a
muscle. The needles are attached by a wire to an EMG machine that records the
electrical activity in the muscle. Damage to a nerve will alter this electrical activity.
/.A nurse is reviewing the medical history of a client who has conductive hearing loss.
The nurse should identify which of the following factors as a potential cause of
conductive hearing loss? SATA
- Trauma to the outer ear
- Damage to inner ear structures
- Inflammation
- Down syndrome
- Cerumen buildup
- Otitis media - Answer-- Trauma to the outer ear
- Inflammation
- Cerumen buildup
- Otitis media
/.A nurse is caring for an older adult client who reports unintended weight loss. The
client reports that their food does not taste right. The nurse should inform the client that
ability to taste which of the following decreases with age? SATA
- Sweet
- Sour
- Spicy
- Bitter
- Salty
- Savory - Answer-- Sour
- Bitter
- Salty