502 Hesi Case Study (Sensory Function)
Fred JohnsonFred Johnson, a 78-year-old retired farmer, visits the primary care health clinic
where he tells the nurse that his vision is getting really bad and that he finds he has to have the
television up pretty loud to hear clearly. The client reports that his family is also getting frustrated
with him because he has to ask them multiple times to repeat conversations in order for him to
hear what they are saying. The nurse prepares to complete an assessment of Fred's sensory
function. - ANS-Meet the Client:
During the initial interview, the registered nurse inspects the external anatomy of the eye. The
eye is a sensory organ of vision, and it is well protected by a bony orbital cavity and surrounded
with a cushion of fat. The nurse notes that the cornea looks cloudy and an arcus senilis is seen
around the cornea. - ANS-Assessment
What action should the nurse take first?
Prepare to assist the HCP in obtaining ocular pressures.
Assess the client's retinal structures.
Assess whether the cornea looks thickened and raised and document the finding.
Document any report of tearing or burning sensation. - ANS-Assess whether the cornea looks
thickened and raised and document this finding
Rationale: As the lipid accumulates, the cornea may look thickened and raised. The assessment
finding should be documented in the EMR
arcus senilis - ANS-gray-white arc or circle around the limbus of the iris that is common with
aging
During the assessment of Fred's hearing, the nurse performs a series of tests, including Fred's
ability to hear whispered and conversational tones.
How will the nurse assess for the presence of Tinitus - ANS-Ask the client if he ever hears
ringing in his ears
Tinnitus is the presence of ringing in the ears, which is often associated with hearing loss
Fred seems nervous and asks for a glass of water. After taking a drink, he attempts to set the
glass down, but places the glass on the edge of the counter, causing it to crash to the floor
, To follow up this situation, which assessment will provide the most useful data?
Mini mental status exam.
Vital signs and level of consciousness.
Visual field and depth perception.
Pupil size and accommodation. - ANS-Visual field and depth perception
Under or over reaching for objects is an indication of a visual deficit. Assessment of visual field
and depth perception will provide the most useful data related to the situation
Fred's visual acuity is measured using a Snellen chart. The reading obtained is 20/200 in the
right eye and 20/80 in the left eye.
How should the nurse explain these findings to Fred?
How should the nurse explain these findings to Fred?
"You are very far-sighted, especially in your left eye."
"You are very near-sighted, especially in your right eye."
"You have macular degeneration in your right eye."
"You may qualify for a corneal transplant." - ANS-You are very near-sighted, especially in your
left eye
The larger the demoninator (bottom number), the poorer the visual acuity. This is commonly
referred to as being near sighted. Standing at 20 feet, the client can ready what the person with
normal at further distances, such as 80 feet (left eye) or 200 feet (right eye)
As the interview continues, the nurse notes that Fred is very pleasant and nods his head in
agreement with all of the nurse's statements, but that he often does not respond to simple
requests during the assessment.
Which nursing diagnosis is best supported by the data available?
Which nursing diagnosis is best supported by the data available?
Noncompliance.
Situational low self-esteem.
Fred JohnsonFred Johnson, a 78-year-old retired farmer, visits the primary care health clinic
where he tells the nurse that his vision is getting really bad and that he finds he has to have the
television up pretty loud to hear clearly. The client reports that his family is also getting frustrated
with him because he has to ask them multiple times to repeat conversations in order for him to
hear what they are saying. The nurse prepares to complete an assessment of Fred's sensory
function. - ANS-Meet the Client:
During the initial interview, the registered nurse inspects the external anatomy of the eye. The
eye is a sensory organ of vision, and it is well protected by a bony orbital cavity and surrounded
with a cushion of fat. The nurse notes that the cornea looks cloudy and an arcus senilis is seen
around the cornea. - ANS-Assessment
What action should the nurse take first?
Prepare to assist the HCP in obtaining ocular pressures.
Assess the client's retinal structures.
Assess whether the cornea looks thickened and raised and document the finding.
Document any report of tearing or burning sensation. - ANS-Assess whether the cornea looks
thickened and raised and document this finding
Rationale: As the lipid accumulates, the cornea may look thickened and raised. The assessment
finding should be documented in the EMR
arcus senilis - ANS-gray-white arc or circle around the limbus of the iris that is common with
aging
During the assessment of Fred's hearing, the nurse performs a series of tests, including Fred's
ability to hear whispered and conversational tones.
How will the nurse assess for the presence of Tinitus - ANS-Ask the client if he ever hears
ringing in his ears
Tinnitus is the presence of ringing in the ears, which is often associated with hearing loss
Fred seems nervous and asks for a glass of water. After taking a drink, he attempts to set the
glass down, but places the glass on the edge of the counter, causing it to crash to the floor
, To follow up this situation, which assessment will provide the most useful data?
Mini mental status exam.
Vital signs and level of consciousness.
Visual field and depth perception.
Pupil size and accommodation. - ANS-Visual field and depth perception
Under or over reaching for objects is an indication of a visual deficit. Assessment of visual field
and depth perception will provide the most useful data related to the situation
Fred's visual acuity is measured using a Snellen chart. The reading obtained is 20/200 in the
right eye and 20/80 in the left eye.
How should the nurse explain these findings to Fred?
How should the nurse explain these findings to Fred?
"You are very far-sighted, especially in your left eye."
"You are very near-sighted, especially in your right eye."
"You have macular degeneration in your right eye."
"You may qualify for a corneal transplant." - ANS-You are very near-sighted, especially in your
left eye
The larger the demoninator (bottom number), the poorer the visual acuity. This is commonly
referred to as being near sighted. Standing at 20 feet, the client can ready what the person with
normal at further distances, such as 80 feet (left eye) or 200 feet (right eye)
As the interview continues, the nurse notes that Fred is very pleasant and nods his head in
agreement with all of the nurse's statements, but that he often does not respond to simple
requests during the assessment.
Which nursing diagnosis is best supported by the data available?
Which nursing diagnosis is best supported by the data available?
Noncompliance.
Situational low self-esteem.
