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
