Neurosensory Disorders

The nervous sytem consists of two divisions: the central nervous system (CNS) including the
brain and spinal cord, and the peripheral nervous system, which includes cranial and spinal
nerves.

1. Carina, 68 years old admitted in Medical City with diagnosis of organic brain syndrome.
The nurse noticed personality changes and judgment impairment. Which of the following
lobes of the brain is the seal for these changes?
A. Frontal
B. Occipital
C. Parietal
D. Temporal

Rationale: Frontal – the largest lobe, located in the front of the skull. The major functions of this
lobe are concentration, abstract thought, information storage or memory, and motor function. It
also contains Broca’s area, critical for motor control of speech. The frontal lobe is also
responsible in large part for a person’s affect, judgment, personality, and inhibitions.

2. Nurse Jeremy is performing a neurological assessment and is checking the spinal

accessory nerve (CN XI). To test the function of this nerve, Nurse Jeremy will ask the
client to do which of the following?
A. Elevate the shoulders.
B. Swallow a sip of water.
C. Open the mouth and say “ah”.
D. Vocalize the sounds “la-la”, “mi-mi”, “kuh-kuh”.

Rationale: Cranial nerve XI (spinal accessory) has a motor type of function significantly to the
sternocleidomastoid and trapezius muscles. To assess its function, the examiner may palpate
and note the strength of trapezius muscles while patient shrugs shoulders against resistance
and/or palpate and note strength of each sternocleidomastoid muscle as patient turns head
against opposing pressure of the examiner’s hand.

Computed tomography (CT) scanning makes use of a narrow x-ray beam to scan the body part
in successive layers. The images provide cross-sectional views of the brain, with distinguishing
differences in tissue densities of the skull, cortex, subcortical structures, and ventricles.

3. Mr. Herrera is scheduled for CT scan for the next day, noon time. Which of the following
is the CORRECT preparation as instructed by Nurse Jeremy?
A. Shampoo hair thoroughly to remove oil and dirt.
B. Shave scalp and securely attach electrodes to it.
C. Insert a padded tongue depressor between his jaws.
D. No special preparation is needed. Instruct the patient to keep his head still and
steadily.

Rationale: Essential nursing interventions include preparation for the procedure and monitoring.
Preparation includes teaching the patient about the need to lie quietly throughout the proceudre.
A review of relaxation techniques may be helpful for patients with claustrophobia.
A lumbar puncture (spinal tap) is carried out by inserting a needle into the lumbar subarachnoid
space to withdraw CSF.

4. The physician orders a spinal tap to confirm the presence of subarachnoid hemorrhage
in a client who had head injury. Nurse Jeremy would INITIALLY place the client in which
of the following positions to prevent post-lumbar puncture headache?
A. Prone during the procedure
B. Flat for 6 hours after the procedure
C. High Fowler’s during the procedure
D. High Fowler’s for 6 hours after the procedure

Rationale: Post-lumbar puncture headache may be avoided if a small gauge needle is used
and if the client remains prone after the procedure. When a large volume of fluid (more than 20
ml) i sremoved, the client is positioned prone for 2 to 3 hours, and then supine or prone for 6
more hours. Keeping the client flat overnight may reduce the incidence of headaches.

An electroencephalogram (EEG) represents a record of electrical activity generated in the brain.

5. A client with a history of seizure will undergo an electroencephalogram (EEG). Which of

the following should the nurse do a day before the actual test?
A. Hold the daily dose of anticonvulsant.
B. Instruct the client to refrain from washing the hair.
C. Place the client on nothing per orem (NPO) status.
D. Reinforce client teaching that the test is only mildly uncomfortable.

Rationale: Antidepressants, tranquilizers, and anticonvulsants are generally withheld for 24 to

48 hours before an EEG.

The rigid cranial vault contains brain tissue (1400 g), blood (75 ml), and CSF (75 mL). The
volume and pressure of this three components are usually in a state of equilibrium and produce
the ICP. ICP is usually measured in the lateral ventricles, with the normal pressure being 10 to
20 mm Hg.

6. In a client at risk for increased intracranial pressure (ICP), which of the following would
be the PRIORITY for the nurse to monitor?
A. Tachycardia
B. Unequal sizes of pupils
C. Decreasing body temperature
D. Decreasing systolic blood pressure

Rationale: Any changes in pupil size, shape, and reactivity indicate an increase in ICP. Of
particular importance is the ovoid pupil, which is regarded as the midstage between a normal-
sized pupil and a dilated pupil. This finding indicates the development of increased ICP.

7. A nurse is positioning a client with increased ICP. Which of the following positions
should the nurse AVOID?
A. Head in midline position
B. Head turned to the side
C. Head in neutral position
D. Head of bed at Semi-Fowler’s position
Rationale: Proper positioning helps to reduce ICP. The head is kept in a neutral position
(midline) position, maintained with the use of cervical collar if necessary, to promote venous
drainage. Elevation of the head is maintained at 0 to 60 degrees to aid in venous drainage
unless otherwise prescribed. Extreme rotation of the neck and flexion of the neck are avoided,
because compression and distortion of the jugular veins increases ICP.

Seizures are episodes of anormal motor, sensory, autonomic, or psychic activity (or a
combination of these) that result from sudden excessive discharge from cerebral neurons. The
two main types are: partial seziures that begin in one part of the brain, and generalized seizures
that involve electrical discharges in the whole brain.

8. Just as Nurse Jeremy was entering the room, the patient who was sitting on his chair
begins to have seizure. Which of the following must Nurse Jeremy do FIRST?
A. Ease the patient to the floor.
B. Lift the patient and put him on bed.
C. Restraint the patient’s body movement.
D. Insert a padded tongue depressor between his jaws.

Rationale: Ease the patient to the floor if possible to prevent injury.

9. During and after seizure, Nurse Jeremy knows that the patient is ALWAYS placed in
what position?
A. Supine
B. Side-lying
C. Low-Fowler’s
D. Modified Trendelenburg

Rationale: The patient with seizure disorder is at risk for hypoxia, vomiting, and pulmonary
aspiration. To prevent complications, the patient is placed in the side-lying position to facilitate
drainage of oral secretions, and suctioning is performed, if needed, to maintain patent airway
and prevent aspiration.

Strokes can be divided into two major categories: ischemic (85%) in which vascular occlusion
and significant hypoperfusion occur, and hemorrhagic (15%), in which there is extravasation of
blood into the brain or subarachnoid space.

10. An elderly client had a stroke an can only see the nasal visual field on one side and the
temporal portion on the opposite side. Which of the the following items describes this
condition?
A. Astereognosis
B. Oculogyric crisis
C. Receptive aphasia
D. Homonymous hemianopsia

Rationale: Visual-perceptual dysfunctions are caused by disturbances of the primary sensory

pathways between the eye and visual cortex. Homonymous hemianopsia (loss of half of the
visual field) may occur from stroke and may be temporary or permanent. The affected side of
vision corresponds to the paralyzed side of the body (Smeltzer et al., 2008: 2209).
 11. April is admitted to the hospital with signs and symptoms of stroke. Which among the
following intervention should Nurse Jeremy consider a the HIGHEST PRIORITY when
caring for April who has hemiparesis, secondary to stroke?
A. Apply anti-embolic stockings.
B. Perform range of motion exercises.
C. Use hand rolls or pillows for support.
D. Place April on an upright lateral position.

Rationale: Correct positioning is important to prevent contractures; measures are used to

relieve pressure, assist in maintaining good body alignment, and prevent compressive
neuropathies, especially of the ulnar and peroneal nerves. The patient’s position should be
changed every 2 hours. To place a patient in a lateral (side-lying) position, a pillow is placed
between legs before the patient is turned. To promote venous return and prevent edema, the
upper thigh should not be acutely flexed. The patient may be turned from side to side, but if
sensation is impaired, the amount of time spent on the affected side should be limited.The head
of bed is elevated 15 to 30 degrees to promote venous drainage and decrease ICP.

12. When performing a neurological assessment to a client with stroke, the nurse should
pay IMMEDIATE attention to:
A. Decrease in level of consciousness
B. Altered sensation to stimuli
C. Loss of bladder control
D. Emotional lability

Rationale: A further decrease in the level of consciousness would be indicatibe of a further

progression of the CVA. It is the nurse’s priority to maintain cerebral oxygenation which is
criticial for the client’s survival and long-term outcome. The earliest manifestation of cerebral
hypoxia is decreasing level of consciousness. Additional manifestations of progressive
deterioration are changes in motor or sensory function, papillary changes, respiratory difficulty,
and development of visual or perceptual defects or aphasia.

Head injury is a broad classification that includes injury to the scalp, skull, or brain. Closed
(blunt) brain injury occurs when the brain tissue is damaged but there is no opening through the
skull and dura. Open brain injury occurs when an object penetrates the skull, enters the brain,
and damages the soft brain tissue and its path.

13. Ronnie, 18-year-old, accidentally bumped his head on the floor during a basketball
game. Several days after the incident, he complained of severe headache and lapsed
into a coma. Nurse Jeremy knows that the MOST possible cause of this is:
A. a temporary brain ischemia.
B. a dislodged blood clot that traveled to the brain.
C. compression of brain tissue due to formed tumor
D. compression of brain tissue due to cerebral edema or hemorrhage

Rationale: As first response to injury, the CSF is shunted or displaced from the cranial
compartment to the spinal subarachnoid space or the rate of CSF absorption is increased. An
additional response if needed, is a decrease in cerebral blood volume by displacement of
cerebral venous blood into the sinuses. Increased ICP occurs when compliance no longer takes
place and the brain cannot accomodate further volume changes. As ICP increases, cerebral
perfusion decreases, leading to tissue hypoxia, a decrease in serum pH level, and an increase
in the level of carbon dioxide. This process causes cerebral vasodilation, edema, and a further
increase in ICP, and the cycle continues. Hemorrhages, which can cause brain hematoma or
clot formation, may occur as part of primary injury and begin at the moment of impact. They may
also be a secondary event arising from vessel damage and occur somewhat later or worsen
later in the client’s clinical course. Classically they are caused by vascular damage from the
shearing force of the trauma or direct physical damage from skull fractures or penetrating injury.
All hematomas are life threatening because they act as space-occupying lesions and
surrounded by edema.

14. Nurse Jeremy is caring for a client diagnosed to have head injury. Which of the following
situations needs intervention by Nurse Jeremy?
A. The padded side rails are up.
B. The bed is adjusted to low level.
C. The head of bed is elevated at 30 degree angle.
D. The client's spouse turns on the TV one hour in the afternoon and 2 hours in the
evening.

Rationale: In a client with head injury, increased ICP occurs. External stimuli should be reduced
to prevent seizures.

Damage to the spinal cord ranges from transient concussion to contusion, laceration, and
compression of the cord substance, to complete transection of the cord which renders the
patient paralyzed below the level of injury.

15. Marvin is admitted in orthopedic hospital due to spinal cord injury. He presented severe
respiratory failure. Which of his spinal nerves has been involved?
A. Sacral 1-5
B. Lumbar 1-5
C. Cervical 1-4
D. Thoracic 2-12

Rationale: Respiratory dysfunction is related to the level of injury. The muscles contributing to
respiration are the abdominals and intercostals (T1 to T11) and the diaphragm (C4). In high
cervical cord injury, acute respiratory failure is the leading cause of death.

16. A 20-year-old male is admitted at the trauma ward with a spinal cord injury at level of T3
due to a sports-related accident. Nurse Jeremy should prepare for the following in the
client’s room to help manage the acute phase of the injury EXCEPT:
A. A firm mattress with a bedboard underneath
B. An oxygen tank and a nasal cannula
C. A cervical traction device
D. Suction equipment

Rationale: Thoracic and lumbar injuries are usually treated with surgical intervention followed
by immobilization with a fitte dbrace. Traction is not indicated before or after surgery. Also the
injury does not involve the cervical spine, thus a cervical traction will not be necessary.

17. Nurse Jeremy is taking care of a patient who has suffered from spinal cord injury. Which
of the following assessments would indicate that the patient is experiencing autonomic
dysreflexia?
A. Sudden tachycardia
B. Pallor of the face and neck
 C. Severe throbbing headache
D. Severe and sudden hypotension

Rationale: Autonomic dysreflexia is an acute emergency that occurs as a result of exaggerated

autonomic responses to stimuli that are harmless in normal people. It occurs only after spinal
shock has been resolved. This syndrome is characterized by a severe, punding headache with
paroxysmal hypertension, profuse diaphoresis, nausea, nasal congestion, and bradycardia. It
occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after
spinal shock has subsided.

18. Nurse Jeremy is a public health nurse, visiting a client who had spinal cord injury. Which
of the following factors should Nurse Jeremy include when giving health teachings?
A. Use of walker
B. Regular schedule for elimination
C. Signs and symptoms of constipation
D. Proper technique of massaging the legs

Rationale: Regular schedule of elimination is very important in a client with spinal cord injury.
Bladder distention and fecal impaction may cause autonomic dysreflexia.

Multiple sclerosis (MS) is an immune-mediated, progressive demyelinating disease of the CNS.

19. Venus, a 45 year old client diagnosed with Multiple Sclerosis (MS) is admitted to the
medical-surgical unit. All of the following are typical manifestations of Multiple Sclerosis
(MS) EXCEPT:
A. Double vision
B. Muscle tremors
C. Sudden bursts of energy
D. Weakness of the extremities

Rationale: The signs and symptoms of MS are varied and multiple, reflecting the location of the
lesion (plaque) or combination of lesions. The primary symptoms most commonly reported are
fatigue, depression, weakness, numbness, difficulty in coordination, loss of balance, and pain.
Visual disturbances due to lesions in the optic nerves or their connections may include blurring
of vision, diplopia, patchy blindness (scotoma), and total blindness.

20. Venus has had multiple scelorosis since she was in her mid-30s and has received
various drug therapies. What is the PRIMARY reason why the nurse finds it difficult to
evaluate the effectiveness of the drugs that the client has used?
A. The client exhibits tolerance to many drugs.
B. The client requires multiple drugs simultaneously.
C. The client experiences spontaneous remissions from time to time.
D. The client endures long periods of exacerbation before the illness responds to a
particular drug.

Rationale: Between 80% and 85% of patients with MS have a relapsing remitting course. With
each relapse, recovery is usually complete; however, residual deficits may occur and
accumulate over time, contributing to functional decline.This is the main reason why it is difficult
to evaluate the drug’s effectiveness.
Myasthenia gravis, an autoimmune disorder affecting the myoneural junction,is chracterized by
varying degrees of weakness of the voluntary muscles..

21. A female client has experienced an episode of myasthenic crisis. Nurse Jeremy would
assess whether the client has precipitating factors such as:
A. getting too little exercise
B. taking excess medication
C. omitting doses of medication
D. increasing intake of fatty foods

Rationale: Myasthenic crisis often is caused by undermedication and responds to the

administration of cholinergic medications, such as neostigmine (Prostigmin) and pyridostigmine
(Mestinon). Cholinergic crisis (the opposite problem) is caused by excess medication and
responds to withholding of medications. Too little exercise and fatty food intake are incorrect.
Overexertion and overeating possibly could trigger myasthenic crisis.

22. Nurse Jeremy is teaching the female client with myasthenia gravis about the prevention
of myasthenic and cholinergic crises. Nurse Jeremy tells the client that this is MOST
effectively done by:
A. eating large, well-balanced meals.
B. doing muscle-strengthening exercises.
C. doing all chores early in the day while less fatigued.
D. taking medications on time to maintain therapeutic blood levels.

Rationale: Clients with myasthenia gravis are taught to space out activities over the day to
conserve energy and restore muscle strength. Taking medications correctly to maintain blood
levels that are not too low or too high is important. Muscle-strengthening exercises are not
helpful and can fatigue the client. Overeating is a cause of exacerbation of symptoms, as is
exposure to heat, crowds, erratic sleep habits, and emotional stress.

Guillain-Barré Syndrome is an autoimmune attack on the peripheral nerve myelin. The result is
acute, rapid segmental demyelination of peripheral nerves and some crenial nerves.

23. Female client is admitted to the hospital with a diagnosis of Guillain-Barré syndrome.
Nurse Jeremy inquires during the nursing admission interview if the client has history of:
A. seizures or trauma to the brain.
B. meningitis during the last 5 years.
C. back injury or trauma to the spinal cord.
D. respiratory or GIT infection during the previous month.

24. Which of the following nursing diagnosis should be given highest priority Nurse Jeremy
in a client diagnosed with Guillain-Barre Syndrome (GBS)?
A. Ineffective coping related to body changes
B. Ineffective sexuality pattern related to paralysis
C. Ineffective breathing pattern related to respiratory muscle weakness
D. Activity intolerance related to peripheral and voluntary muscle weakness

Rationale: In GBS, respiratory muscle weakness and paralysis occur. The major goal is to
improve respiratory function because of rapidly progressive weakness and impending
respiratory failure.
Parkinson’s disease is associated with decreased levels of dopamine resulting from destruction
of pigmented neuronal cells in substantia nigra in the basal ganglia region of the brain.

25. Mang Antonio, a 65-year-old retired assembly-line worker, is admitted to the hospital
with a diagnosis of Parkinson’s disease. Which of the following should Nurse Jeremy
FIRST expect to see in a patient suspected of having Parkinson’s disease?
A. Tremor
B. Rigidity
C. Akinesia
D. Bradykinesia

Rationale: PD is separated into stages according to the symptoms and degree of disability.
Stage 1 is mild disease with unilateral limb involvement. Bilateral lim involvement occurs in
stage 2. In stage 3, the client exhibits significant gait disturbances and moderate generalized
disability. Stage 4 is characterized by severe disability, akinesia, and muscle rigidity. The client
with stage 5 disease is completely dependent in all ADLs.

26. Nurse Jeremy develops a teaching plan for Mang Antonio. Which of the following topics
in the nurse’s plan is the MOST important to discuss?
A. Maintaining a balanced diet
B. Maintaining a safe environment
C. Developing the immune system
D. Engaging in diversional activities

Rationale: Balance may be adversely affected because of the rigidity of the arms (arm swinging
is necessary in normal walking) which makes them at risk for injury. Special walking techniques
must be learned to offset the shuffling gait and the tendency to lean forward. Safety is most
important to include in the discussion as per Maslow’s Hierarchy of Needs.

Trigeminal neuralgia ia a condition of the fifth cranial nerve that is characterized by paroxysms
of pain in the area innervated by any of the three branches, but most commonly the second and
third branches of the trigeminal nerve.

27. Nurse Jeremy is caring for a client with trigeminal neuralgia (tic douloureaux). To assist
the client with nutritional needs, the nurse should:
A. assist the client to sit in a chair for meals.
B. offer small meals of high-caloric soft foods.
C. encourage the client to eat fish, liver, and chicken.
D. provide additional servings of fruits, and raw vegetables.

Rationale: If the client is losing weight because of poor appetite due to the pain, assist in
selecting foods that are high in calories and nutrients, to provide more nourishment with less
chewing. Suggest that freauent, small meals be eaten instead of three large ones. To minimize
jaw movements when eating, suggest that foods be pureed.

Bell’s palsy (facial paralysis) is caused by unilateral inflammation of the seventh cranial nerve,
which results in weakness or paralysis of the facial muscles on the affected side.

28. Which of the following nursing diagnoses would be a PRIORITY in caring for a client with
Bell’s Palsy?
 A. Acute pain
B. Disturbed body image
C. Disturbed sensory perception (gustatory)
D. Imbalanced nutrition less than body requirements

Rationale: Eating may be difficult for the client due to nerve sensitivity and discomfort. To be
able to meet the client’s nutritional needs, pain should be controlled first.

The optic nerve is also known as the second cranial nerve (CN II). Its purpose is to transmit
impulses from the retina to the occipital lobe of the brain.

29. When completing an assessment of the client’s visual acuity, which of the following
would be APPROPRIATE?
A. Use of a penlight
B. Use of a Snellen Chart
C. Testing the visual fields
D. Use of an ophthalmoscope

Rationale: Testing visual acutiy is the standard, routine method used to determine clarity of the
ocular media. The measurement of visual acuity includes the Snellen chart to test cranial nerve
II.

Low vision is defined as best corrected visual acuity (BCVA) of 20/70 to 20/200. Blindness is
defined as a BCVA that can range from 20/400 to no light perception (NLP). The clinical
definition of absolute blindness is the absence of light perception. Legal blindness is a condition
of impaired vision in which a person has BCVA that does not exceed 20/200 in the better eye.

30. The family of Mr. Ilagan is concerned that he will eventually be blind due to the course of
an illness. Nurse Jeremy should include the following in the family teaching to help Mr.
Ilagan cope with the possibility of blindness EXCEPT:
A. marking medication bottles with textured paints.
B. repositioning articles and furnitures every week.
C. helping the client familiarize herself with spatial orientation.
D. using the clock system to describe the location of food on the plate.

Rationale: Articles and furnitures should be positioned in a consistent place to help the client
navigate thorugh the room. Repositioning every week would confuse the client and can be a
cause of injury.

Glaucoma is a group of ocular conditions characterized by optic nerve damage. The optic nerve
damage is related to the IOP caused by congestion of aqeous humor in the eye.

31. Mr. Diaz has been diagnosed as having chronic open-angle glaucoma. He has been
admitted to the hospital for treatment. The nurse identified a nursing problem of
disturbed sensory perception, visual impairment characterized by:
A. loss of night vision
B. loss of central vision
C. sudden loss of eyesight
D. loss of peripheral vision
Rationale: Glaucoma is often called the “silent thief of sight” because most patients are
unaware that they have the disease until they have experienced visual changes and vision loss.
The patient may not seek health care until he or she experiences blurred vision or “halos”
around lights, difficulty focusing, difficulty adjusting eyes in low lighting, loss of peripheral vision,
aching, or discomfort around the eyes, and headache.

32. A tonometry test was undertaken to Mr. Diaz. Which of the following results should the
nurse expect?
A. The client’s visual acuity is 20/250.
B. The client has decreased peripheral vision
C. The client’s intraocular pressure is 30 mm Hg
D. The client’s eye exhibited the presence of protein falre.

Rationale: Tonometry measures the client’s intraocular pressure by determining the amount of
force necessary to indent of flatten (applanate) a small anterior area of the globe of the eye. The
principle involved is that a soft eye is dented more easily than a hard eye. Normal IOP is 8-21
mm Hg. Since the client has chronic open-angle glaucoma, it is expected that the client will
exhibit an elevated IOP.
33. Diamox is a drug used in the treatment of glaucoma. Which of these is the effect of this
drug?
A. Constricts the pupil
B. Acts as osmotic diuretic
C. Facilitates outflow of aqeous humor
D. Reduces the production of aqeous fluid

Rationale: Carbonic anhydrase inhibitors such as acetazolamide (Diamox), methazolamide,

and dorzolamide decreases aqeous humor production.

Cataract is a lens opacity or cloudiness. According to WHO, cataract is the leading cause of
blindness in the world.

34. Nurse Jeremy is gathering data from a patient who has a history of cataracts. Which of
the following complaints would the patient relate to Nurse Jeremy?
A. Blurred vision
B. Eye dryness
C. Eyepain
D. Floaters

Rationale: Painless, blurry vision is characteristic of cataracts. The person perceives that
surroundings are dimmer, as if his or her glasses need cleaning. Light scattering is common,
and the person experiences reduced contrast sensitivity, sensitivity to glare, and reduced visual
acuity.

35. A client with cataract was scheduled to undergo extracapsular surgery for cataract
extraction. Which of the following activities is NOT encouraged to the patient after the
eye surgery?
A. sexual intercourse, straining during bowel movement, and lifting
B. coughing, blowing the nose, and wearing a metal shield at night
C. reading books, wearing sunglasses during the day, and rubbing the eyes
D. wearing tight shirt collars, bending at the knees, and watching large screen TV’s
Rationale: To reduce increases in IOP, the client and family should be taught about activity
restrictions. Sexual intercourse can cause a sudden rise in IOP. Straining and lifting should also
be avoided to prevent increased IOP. Patients are given laxatives to avoid streaining during
bowel movement.

Although the retina is composed of multiple microscopic layers, the two innermost layers, the
sensory retina and retinal pigment epithelium (RPE), are the most relevant to common retinal
disorders.

36. The client complains to the nurse that she is seeing painless dots on her vision and
flashing lights. The nurse notifies the physician immediately knowing that this may
indicate:
A. Glaucoma
B. Conjunctivitis
C. Retinal detachment
D. Macular degeneration

Rationale: In retinal detachment, patients may report the sensation of shade or curtain coming
across the vision of one eye, cobwebs, bright flashing lights, or the sudden onset of a great
number of floaters (dots). Patients do not complain of pain.

Hearing is conducted over two pathways: air and bone. A general estimate of hearing can be
made by assessing the the patient’s ability to hear a whispered phrase or a ticking watch. The
Weber and Rinne tests may be used to distinguish conductive loss from sensorineural loss
when hearing is impaired.

37. Nurse Jeremy is assessing a client who presents with decreased hearing. Which of the
following findings indicate the NEED FOR FURTHER evaluation?
A. Whispered words are repeated at two feet
B. Sound is heard equally on both ears with Weber test
C. Pearly gray tympanic membrane is observed with an otoscope
D. Bone conduction is heard twice as long as air conduction with Rinne test

Rationale: In the Rinne test, the client should hear air conduction twice as long as bone
conduction.

Hearing loss is one of the country’s primary disabilities. It diminishes the quality of life of adults,
and thus, health care providers should be aware on the dynamics of this disability.

38. Which of the following indicates POOR practice in communicating with a hearing-
impaired client?
A. Face the client while talking.
B. Converse in a quiet room with minimal distractions.
C. Speak clearly in a loud voice when talking to the client.
D. Keep hands and other objects away from mouth when talking to the client.

Rationale: Shouting raises the frequency of the sound and often makes understanding the
words difficult. It is enough for the nurse to speak clearly and slowly.

Meniere’s disease is an abnormal inner ear fluid balance caused by malabsorption in the
endolymphatic sac, or a blockage in the endolymphatic duct.
 39. Nurse jeremy is giving dietary instructions to the client. Which statement if made by the
client indicates that the teaching has been SUCCESSFUL?
A. “I will not eat chocolates, and yoghurt.”
B. “I must drink at least 3,000 ml of fluids per day.”
C. “I will try to eat foods that are low in sodioum and limit my fluid intake.”
D. “I will try to follow a 50% carbohydrate, 30% fat, and 20% protein diet.”

Rationale: Clients are advised to limit fluid and sodium intake so as not to further cause
accumulation of fluids in the endolymph.

40. A client is diagnosed with Meniere’s disease. The PRIORITY nursing diagnosis for this
client is:
A. Risk for injury
B. Impaired social interaction
C. Altered cerebral tissue perfusion
D. Altered nutrition more than body requirments

Rationale: The client has an attack of incapacitating vertigo and the client is at high risk for
injury due to falls. The client will perceive that the environment is moving due to disruption of the
vestibular system of the ear’s normal function.

Post-Script Questions

1. A nurse is collecting data from a client admitted to the hospital who has right-sided
weakness, aphasia, and urinary incontinence. One of the client’s family member states,
“This is the end if this is a stroke.” The nurse makes which therapeutic response to the
family member?
A. “A stroke does not mean the end.”
B. “These symptoms may be reversible.”
C. “Do you feel as if your family member is dying?”
D. “Wait until the doctor gets here before you think that way.”

2. A client with Parkinson’s disease is embarassed about symptoms of the disorder and is
withdrawn. Which approach is therapeutic in assisting the client to cope with the
disease?
A. Assist the client with ADLs as much as possible.
B. Plan only a few activities for the client during the day.
C. Cluster activities at the end of the day when the client is most withdrawn.
D. Encourage and praise perseverance in performing activities of daily living (ADLs).

3. The client is diagnosed to have Amyotrophic Lateral Sclerosis (ALS). Which of the
following signs and symptoms should concern the nurse MOST?
A. Tremors
B. Muscle atrophy
C. Ptosis of the eyelid
D. Difficulty in swallowing
 4. The nurse would assess which of the following types of vision loss in a client with age-
related macular degeneration?
A. Total blindness
B. Central vision loss only
C. Peripheral vision loss only
D. Seeing “halos” and “cobwebs”

5. Mr. John Lloyd is cleaning the garage and splashes a chemical to his eyes. The INITIAL
PRIORITY care following the chemical burn is to:
A. Assess the client’s ocular muscles.
B. Transport to a physician immediately.
C. Irrigate with normal saline for 1 to 15 minutes.
D. Bring the client to a medical mission whose services are free.

“If any of you lack wisdom, let him ask of God that giveth to all
liberally, and upbraideth not; and it shall be given him.” James 1:5