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NSC 114 Exam 4 Questions with Correct Answers
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NSC 114 Exam 4 Questions with Correct Answers Lumbar puncture: positioning of client - Answer-Lateral with head bent toward chest, knees flexed to abdomen, back at the edge of the bed or examination table Abdominal paracentesis - Answer-Relieves pressure on the abdominal organs Obtain a fluid ...

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  • August 24, 2024
  • 24
  • 2024/2025
  • Exam (elaborations)
  • Questions & answers

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  • nsc 114
  • nsc 114 exam 4
  • nsc 114 exam 4 questions with correct answers
  • lumbar puncture positioning of client

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NSC 114 Exam 4 Questions
with Correct Answers
Lumbar puncture: positioning of client - Answer-Lateral with head bent toward chest,
knees flexed to abdomen, back at the edge of the bed or examination table

Abdominal paracentesis - Answer-Relieves pressure on the abdominal organs
Obtain a fluid specimen for lab study

Thoracentesis - Answer-To remove excess fluid/air to ease breathing OR to introduce
chemotherapeutic drugs intrapleurally

Thoracentesis: nurse's role - Answer-Assist client to assume a position that allows easy
access to the intercostals space

Positions for Thoracentesis - Answer-Sitting on one side with arm held to the front and
up
Sitting and leaning forward over a pillow

Bone marrow biopsy - Answer-Removal of a specimen of bone marrow for lab study

Bone marrow biopsy: bones usually used - Answer-Sternum, iliac crest,
anterior/posterior iliac spines, proximal tibia in children, posterior superior iliac crest

What is the preferred site for a bone marrow biopsy - Answer-Posterior superior iliac
crest

How to promote health sensory function - Answer-Early detection/screening,
appropriate sensory input, visual impairment associated with greater difficult in
performing ADLs

Most common vision diseases in the elderly - Answer-Macular degeneration, cataract,
glaucoma, diabetic retinopathy

Impaired smell requires - Answer-Caution with/around chemicals and food

Impaired touch can lead to - Answer-Burns or pressure ulcers

Interventions with impaired touch to prevent injury - Answer-Test bath water with a
thermometer and change positions often

,Hearing impairment requires - Answer-Substituting visual cues to signal danger

Hearing impairment with older adults - Answer-Allow more time for processing


Liver biopsy: long or short procedure - Answer-Short


Sensory reception - Answer-Process of receiving stimuli or data

Kinesthetic - Answer-Awareness of position and movement of body part

Stereognosis - Answer-Identify an object through touch

Kinds of stimuli to receive - Answer-Visual, auditory, olfactory, tactile, gustatory,
visceral, kinesthetic, and stereognosis

Sensory perception - Answer-Conscious organization and translation of data into
meaningful information

Nursing process- 4 aspects that must be present - Answer-Stimulus, receptor, impulse
conduction, perception

To receive and interpret stimuli, the _______ must be ________ - Answer-Brain, alert

Sensoristasis - Answer-State of optimal arousal

Awareness - Answer-Perceive and respond appropriately to stimuli

Receiving and interpreting stimuli is mediated by - Answer-Reticular activating system in
brain stem

What does RAS stand for - Answer-reticular activating system

______ can adapt to stimuli - Answer-Brain

Factors influencing sensory function - Answer-Developmental stage, culture, level of
stress, medications, illness, lifestyle, and personality

Sensory alterations - Answer-Too much or too little stimulation can cause difficulties

Clinical manifestations of sensory deprivation - Answer-Excessive yawning, drowsiness,
ad sleeping
Decreased attention span, difficulty concentrating, and decreased problem solving
Impaired memory, periodic disorientation, general confusion, or nocturnal confusion
Preoccupation with somatic complaints (palpitations)

, Hallucinations/delusions
Crying, annoyance over small matters, and depression
Apathy and emotional liability

Clinical manifestations of sensory overload - Answer-Complaints of fatigue,
sleeplessness
Irritability, anxiety, and restlessness
Periodic or general disorientation
Reduced problem-solving ability and task performance
Increased muscle tension
Scattered attention and racing thoughts

Sensory deficit - Answer-Impaired reception, perception, or both
Usually can adapt if loss is gradual
Sudden loss is disorienting
Deficit can lead to both sensory deprivation and sensory overload

Parts of sensory-perceptual function assessment - Answer-Nursing history, mental
status exam, identification of clients at risk, client's environment, social support network

Clients at risk for sensory deprivation - Answer-Nonstimulating/monotonous
environment, impaired vision/hearing, mobility restrictions, inability to process stimuli,
emotional disorders, limited social contact

Clients at risk for sensory overload - Answer-Pain/discomfort, admission to an acute
care facility, monitoring in intensive care units, invasive tubes, decreased cognitive
ability

Sensory/perception NANDAs - Answer-Acute confusion
Chronic confusion
Impaired memory
Risk for acute confusion

NANDAs with sensory-perceptual disturbances as etiology - Answer-Risk for injury
Impaired home maintenance
Risk for impaired skin integrity
Impaired verbal communication
Social isolation

Goals for sensory-perception NANDAs - Answer-Prevent injury
Maintain function of existing senses
Develop an effective communication mechanism
Prevent sensory overload/deprivation
Reduce social isolation
Perform ADLs independently and safely

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