N1120 Test Blueprint Unit XI Alterations in Sensory ...



Alterations in Sensory Stimulation Test Questions/Blueprint

|Question |Course Objective |Step in the Nursing |Cognitive Level |Difficulty Level|Item |Response |

| | |Process |(Blooms) | |Discrim. | |

|1. Which of the following hospitalized patients would be at MOST risk of experiencing | |assess |Remember |0.909 |0.2 | |

|sensory overload? | | |Understand | | | |

|a. Normal eight-week-old infant. | | | | | | |

|b. 24-year-old male in a lower leg cast. | | | | | | |

|c. 44-year-old female who left her reading glasses at home. | | | | | | |

|d. 56-year-old male in the intensive care unit following a heart attack | | | | | | |

|2. Mrs. Pate is an 80-year-old widow who has recently become a resident of a long term care | |Assess |Understand |1.000 |0.0 | |

|facility. Three days after she is admitted, the nurse finds her to be somewhat confused and| |implement |apply | | | |

|disoriented about person, place, and time. Which of the following interventions by the | | | | | | |

|nurse is MOST appropriate? | | | | | | |

|a. Reorient Mrs. Pate to person, place, and time as often as possible. | | | | | | |

|b. Use a posey vest restraint to keep Mrs. Pate from falling out of bed. | | | | | | |

|c. Encourage diversional activity, such as watching television. | | | | | | |

|d. Touch and stroke Mrs. Pate frequently. | | | | | | |

|3. The nurse is working with a client in an extended care facility. To enhance the clients | |Assess |Understand |1.000 |0.0 | |

|Gustatory (taste) senses, the nurse should: | |implement |apply | | | |

|Mix foods together | | | | | | |

|Ensure and provide adequate oral hygiene | | | | | | |

|Provide foods with similar texture and consistency | | | | | | |

|Make sure foods are extremely spicy | | | | | | |

|4. Your patient has been in the intensive care unit for 4 days and has begun to show signs | |assess |Understand |0.909 |0.2 | |

|of restlessness and anxiety even though they have been reassured that their condition is | | |apply | | | |

|improving and discharge to the step-down unit will be occurring soon. The cause of the | | | | | | |

|client’s emotional state is likely a result of: | | | | | | |

|a. Fear of death | | | | | | |

|b Social isolation | | | | | | |

|c Sensory overload | | | | | | |

|d Anxiety disorder | | | | | | |

|5. . When obtaining a health history from a patient, which statement will be of | |assess |Understand |0.987 |0.1 | |

|most concern to the nurse? | | |apply | | | |

|“My vision seems blurry now when I read the last few weeks” | | | | | | |

|“I have noticed that my eyes are drier now” | | | | | | |

|“It’s hard for me to see when I drive at night” | | | | | | |

|“The middle part of my vision has decreased suddenly today” | | | | | | |

| | | | | | | |

|6. The nurse is obtaining a health history for a 64-year-old patient with glaucoma who is a | |assess |Understand |0.935 |-0.2 | |

| | | |apply | | | |

|new patient at the eye clinic. Which information given by the patient will have the most | | | | | | |

|implications for which eye drops will be used to treat her? | | | | | | |

|“I use aspirin when I have a sinus headache” | | | | | | |

|“I have not had an eye examination for at least 10 years” | | | | | | |

|“I take metoprolol daily for angina” | | | | | | |

|“I have had frequent episodes of conjunctivitis” | | | | | | |

|6. | | | | | | |

|7. Carbonic anhydrase inhibitors such as Diamox may be given to patients with glaucoma to: | |assess |Understand |0.558 |0.3 | |

|a. Constrict the pupil to open the angle. | | |apply | | | |

|b. Draw fluid from the eye into vascular circulation. | | | | | | |

|c. Decrease production of aqueous humor. | | | | | | |

|d. Increase outflow of aqueous humor. | | | | | | |

|8. When administering Timolol (timoptic) eye gtts, it is important for the nurse to do, or | |assess |Understand |0.766 |0.2 | |

|educate the patient to do this after administering: | | |apply | | | |

|Assess heart rate before administering | | | | | | |

|Maintain pressure over the lacrimal sac to prevent systemic absorption | | | | | | |

|Administer at bedtime to decrease side effects | | | | | | |

|a & b | | | | | | |

|9. The nurse is caring for a patient with conjunctivitis of the left eye who | |implement |Understand |1.000 |0.0 | |

|has Sulfacetamide eye drops prescribed for use in the affected eye. The nurse explains that | | |apply | | | |

|to help prevent the spread of infection, the patient should: | | | | | | |

|Apply an occlusive dressing to the affected eye | | | | | | |

|Avoid touching the eyes and wash hands frequently | | | | | | |

|Use the eye drops in both eyes as a prophylactic measure | | | | | | |

|Apply corticosteroid ointment to the right eye to decrease the risk of inflammation | | | | | | |

|10. A patient is prepared for discharge following outpatient cataract surgery. To evaluate | |Implement |Understand |0.935 |0.0 | |

|whether the patient understands the postoperative regimen and procedures, the nurse asks the| | |apply | | | |

| | | | | | | |

|patient: | | | | | | |

|To use the 0 to 10 pain scale to rate eye pain | | | | | | |

|To demonstrate administration of prescribed eye drops | | | | | | |

|To state how good the vision is in the operative eye | | | | | | |

|Why staying on bed rest for 24 hours is needed | | | | | | |

|11. A patient who had cataract extraction and intraocular lens implantation the previous | |Assess |Understand |0.740 |0.5 | |

|day calls the eye clinic and gives the nurse the following information. Which information is| | |Apply | | | |

|of | | |evaluate | | | |

|most concern to the nurse? | | | | | | |

|The patient has rated their eye pain at a 5 (on a 0-10 scale) | | | | | | |

|The patient complains that their vision has not improved tremendously | | | | | | |

|The patient has poor depth perception when wearing an eye patch | | | | | | |

|The patient has questions about the ordered eye drops | | | | | | |

|12. . A patient who has heart failure and has been receiving large doses if IV | |assess |Understand |0.779 |0.3 | |

|furosemide | | |apply | | | |

|(Lasix) tells the nurse, “I cannot hear very well. My ears are ringing” The most appropriate| | | | | | |

|action | | | | | | |

|by the nurse is to | | | | | | |

|Arrange for the patient to have a hearing test | | | | | | |

|Withhold the ordered dose of furosemide and notify the physician | | | | | | |

|Tell the patient that these symptoms are temporary | | | | | | |

|Add the nursing diagnosis of disturbed auditory perception related to ototoxicity to the | | | | | | |

|patient’s care plan | | | | | | |

|13. 1120-XI-9 A patient with Meniere’s disease is admitted with vertigo, nausea, and | |implementation |Understand |0.883 |0.3 | |

|vomiting. Which | | |apply | | | |

|nursing intervention will be included in the care plan? | | | | | | |

|Encourage oral fluids to 3000mL daily | | | | | | |

|Change the patient’s position every 2 hours | | | | | | |

|Keep the head of the bed elevated 15 degrees | | | | | | |

|Keep the patient’s room darkened | | | | | | |

|14. The most appropriate nursing action for a patient with epistaxis is: | |implement |Understand |0.805 |0.2 | |

|a. Decrease exposure to allergens. | | |apply | | | |

|b. Heated mist and saline irrigation. | | | | | | |

|c. Application of ice or cool compresses to the nasal bridge. | | | | | | |

|d. Direct pressure to the lower portion of nose. | | | | | | |

|e. c & d | | | | | | |

|15. The use of a hearing aid is most effective for which of the following conditions? | |assess |Understand |0.935 |0.0 | |

|a. Conductive hearing loss | | |apply | | | |

|b. Serous otitis media | | | | | | |

|c. Tinnitis | | | | | | |

|d. Sensorineural hearing loss | | | | | | |

| 16 The patient you are caring for has dysarthria. Which nursing action is most | |Assess |Understand |0.701 |0.5 | |

|appropriate? | |implement |apply | | | |

|a. Place objects within the patient’s reach on the non-affected side. | | | | | | |

|b. Provide a supportive device for ambulation. | | | | | | |

|c. Place food on the unaffected side of the mouth. | | | | | | |

|d. Provide the patient with alternative methods of communicating. | | | | | | |

| | | | | | | |

|17. The daughter of a patient admitted unconscious to the ER with a possible stroke | |assess |Understand |0.831 |0.3 | |

|reports that her mother has a history of hypertension that she does not manage well. She has| | |apply | | | |

| | | | | | | |

|been using estrogen replacement therapy for the past 6 years, and estrogen and her | | | | | | |

|antihypertensive medication are the only drugs she uses. Her only activity is managing her | | | | | | |

|home, | | | | | | |

|and she appears quite overweight. The finding that the nurse recognizes as the most | | | | | | |

|significant | | | | | | |

|risk factor for stroke in this patient is | | | | | | |

|a. Obesity | | | | | | |

|b. Hypertension | | | | | | |

|c. Sedentary lifestyle | | | | | | |

|d. Estrogen replacement therapy | | | | | | |

| 18. A client has been admitted to the hospital after having a stroke. What predisposing | |assess |Understand |0.857 |0.3 | |

|factor in this patient’s history places this client at risk for an embolic stroke? | | |apply | | | |

|a. A history of hypertension | | | | | | |

|b. A history of psychotropic drug use | | | | | | |

|c. A history of atrial fibrillation | | | | | | |

|d. A history of cerebral aneurysm | | | | | | |

|19. The nurse identifies the nursing diagnosis of impaired verbal communication for a | |Assess |Understand |0.961 |0.1 | |

|patient with expressive aphasia. An appropriate nursing intervention to help the patient | |Implement |apply | | | |

|communicate is to: | | | | | | |

|Ask simple questions that the patient can answer with “yes” or “no.” | | | | | | |

|Develop a list of words that the patient can read and practice reciting. | | | | | | |

|Have the patient practice facial and tongue exercises to improve motor control necessary | | | | | | |

| | | | | | | |

|for speech. | | | | | | |

|Prevent embarrassing the patient by changing the subject if the patient does not respond | | | | | | |

|in a timely manner | | | | | | |

|20. A patient with a stroke has progressive development of neurologic deficits with | |Assess |Understand |0.468 |0.4 | |

|increasing weakness and decreased level of consciousness (LOC). The nursing priority that is| |implement |apply | | | |

|most relevant to guide your care at this time will be: | | | | | | |

|Risk for impaired skin integrity r/t immobility | | | | | | |

|Disturbed sensory perception r/t brain injury | | | | | | |

|Risk for aspiration r/t inability to protect airway | | | | | | |

|Impaired physical mobility r/t weakness | | | | | | |

KEY:

|Cognitive Level: |Item Discrimination = how well an item distinguishes between high and low scoring students. |

|Remembering |0 is OK if it’s info that everyone absolutely needs to know, i.e. key content. |

|Understanding |.2 to .3 is desirable for most |

|Applying |.4 or higher is OK for just a few questions. If all were .4, most of our students would fail the test. |

|Analyzing |Negative discrimination means a problem, like a poorly written question, mis-speaking in lecture, not fully clarifying a topic, or an error on the answer key. |

|Evaluating | |

|Creating | |

FINAL EXAM

|ALTERATION IN SENSORY STIMULATION (5) | |assess |Understand |0.937 |0.2 | |

|When obtaining a patient’s admission history, the patient states he has been | | | | | | |

|using Timoptic (Timolol) eye drops for several months. The nurse is aware that| | | | | | |

|this is usually prescribed to treat: | | | | | | |

|Macular degeneration | | | | | | |

|Cataracts | | | | | | |

|Conjunctivitis | | | | | | |

|Glaucoma | | | | | | |

|Your patient has a history of vision problems including a gradual loss of | |assess |Understand |0.734 |0.0 | |

|visual acuity and generalized blurry vision. The patient has no pain in the | | |apply | | | |

|eyes. These symptoms are most usually associated with: | | | | | | |

|Macular degeneration | | | | | | |

|Conjunctivitis | | | | | | |

|Myopia | | | | | | |

|Cataracts | | | | | | |

|Your patient has two different eye drops ordered for a new diagnosis of | |implement |Understand |0.835 |0.0 | |

|glaucoma. How long should you teach to wait between successive eye drops in the| | |apply | | | |

|same eye to achieve adequate eye drop drug retention and absorption? | | | | | | |

|1 minute | | | | | | |

|5 minutes | | | | | | |

|c.30 minutes | | | | | | |

|d.60 minutes | | | | | | |

|A patient admitted with a stroke is coming to your unit from the emergency | |assess |Understand |0.949 |0.1 | |

|department. What assessment data is indicative of a stroke? | | |apply | | | |

|Facial droop | | | | | | |

|Dysarthria | | | | | | |

|hemiparesis | | | | | | |

|a & b | | | | | | |

|a, b, c | | | | | | |

|Your patient who suffered an ischemic stroke now has disturbed visual | |implement |Understand |0.848 |0.1 | |

|perception (visual field cut). What intervention will be required when caring | | |apply | | | |

|for this patient? | | | | | | |

|The patient should be approached on the side where visual perception is intact.| | | | | | |

|Attention to the affected side should be minimized. | | | | | | |

|The patient should avoid repetitious turning of his head in the direction of | | | | | | |

|the defective visual field in order to minimize dizziness. | | | | | | |

|The patient should be approached on the opposite side of where the visual | | | | | | |

|perception is intact in order to increase perception and vision. | | | | | | |

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