MULTIPLE CHOICE
1. A nursing report on a newly admitted patient who is profoundly deaf says that the patient is confused and difficult to assess because she does not appropriately respond to questions or sometimes fails to respond at all: What should be the first action of the oncoming nurse?
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Chapter 58: Special Senses Introduction
Linton: Medical-Surgical Nursing, 7th Edition
MULTIPLE CHOICE
1. A nursing report on a newly admitted patient who is profoundly deaf says that the patient
is confused and difficult to assess because she does not appropriately respond to questions
or sometimes fails to respond at all: What should be the first action of the oncoming
nurse?
a. Consider asking the physician to assess the patient for dementia:
b. Assess the patient to determine whether her hearing aids are in:
c. Report to the physician that the patient is exhibiting signs of the sundown
syndrome:
d. Assess the patient’s medications to check for an overdose:
ANS: B
Profoundly deaf persons can be mistakenly assessed as being confused or disoriented
when not wearing their hearing aids:
DIF: Cognitive Level: Application REF: pp: 1161-1162
OBJ: 3 TOP: Hearing Aids
KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
2. Which patient problem would the nurse prioritize for a patient having ear surgery?
a. Altered self-concept
b. Potential injury
c. Knowledge deficit
d. Inability to communicate effectively
ANS: B
Patients who have had ear surgery are at risk for vertigo, fluid accumulation, or
pressure in the operative ear: Because of the surgery and potential postoperative
, conditions, the patient may be at risk for a fall:
DIF: Cognitive Level: Application REF: p: 1167 OBJ: 3
TOP: Care Planning for Ear Surgery KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection
Control
3. What significant instruction should a nurse include to a patient being discharged after ear
surgery?
a. Use stool softeners with caution:
b. Assume your usual activities:
c. Avoid blowing your nose:
d. Shampoo your hair with baby shampoo:
ANS: C
The patient should avoid blowing the nose to prevent back pressure in the Eustachian
tube: the patient should take stool softeners, limit activity until balance returns, and
delay shampooing:
DIF: Cognitive Level: Application REF: p: 1166 OBJ: 3
TOP: Nursing Diagnosis and Outcome Criteria
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease
4. A patient with diabetes says that he needs a hearing aid because he cannot hear well, and
everything sounds garbled and distant: What type of hearing loss should the nurse
suspect?
a. Mixed hearing loss
b. Conductive hearing loss
c. Central hearing loss
d. Sensorineural hearing loss
ANS: D
A patient with long-term diabetes may have a sensorineural hearing loss that is not
helped by hearing aids:
, DIF: Cognitive Level: Comprehension REF: p: 1162 OBJ: 3
TOP: Types of Hearing Loss KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. Which is the most appropriate concern when considering the impact of a hearing deficit
when planning care for a child who has been diagnosed with a hearing impairment?
a. Potential injury
b. Decreased socialization
c. Knowledge deficit
d. Anxiety
ANS: B
The loss of hearing and the mild stigma associated with hearing impairment place the
newly diagnosed child at risk for social isolation:
DIF: Cognitive Level: Application REF: p: 1165 OBJ: 3
TOP: Impact of Hearing Impairment KEY: Nursing Process Step: N/A
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
6. An 85-year-old patient has had age-related changes in the cochlea: What is the most
appropriate nursing action for the nurse to implement?
a. Speak slowly:
b. Provide assistance with ambulation:
c. Speak in a lower tone:
d. Communicate with the patient in writing:
ANS: B
Assisting the patient when ambulating will diminish the risk of a fall: Changes in the
cochlea will cause dizziness and ataxia:
DIF: Cognitive Level: Application REF: p: 1156 OBJ: 3
TOP: Age-Related Changes KEY: Nursing Process Step: Assessment
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection
Control
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