N1120 Test Blueprint Unit XI Alterations in Sensory Stimulation

Alterations in Sensory Stimulation Test Questions/Blueprint

Question / Course Objective / Step in the Nursing Process / Cognitive Level
(Blooms) / Difficulty Level / Item
Discrim. / Response
1. Which of the following hospitalized patients would be at MOST risk of experiencing sensory overload?
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 / assess / Remember
Understand / 0.909 / 0.2
2. Mrs. Pate is an 80-year-old widow who has recently become a resident of a long term care facility. Three days after she is admitted, the nurse finds her to be somewhat confused and 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. / Assess
implement / Understand
apply / 1.000 / 0.0
3. The nurse is working with a client in an extended care facility. To enhance the clients
Gustatory (taste) senses, the nurse should:
a. Mix foods together
b. Ensure and provide adequate oral hygiene
c. Provide foods with similar texture and consistency
d. Make sure foods are extremely spicy / Assess
implement / Understand
apply / 1.000 / 0.0
4. Your patient has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety even though they have been reassured that their condition is 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 / assess / Understand
apply / 0.909 / 0.2
5. . When obtaining a health history from a patient, which statement will be of most concern to the nurse?
a. “My vision seems blurry now when I read the last few weeks”
b. “I have noticed that my eyes are drier now”
c. “It’s hard for me to see when I drive at night”
d. “The middle part of my vision has decreased suddenly today” / assess / Understand
apply / 0.987 / 0.1
6. The nurse is obtaining a health history for a 64-year-old patient with glaucoma who is a
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?
a. “I use aspirin when I have a sinus headache”
b. “I have not had an eye examination for at least 10 years”
c. “I take metoprolol daily for angina”
d. “I have had frequent episodes of conjunctivitis”
6. / assess / Understand
apply / 0.935 / -0.2
7. Carbonic anhydrase inhibitors such as Diamox may be given to patients with glaucoma to:
a. Constrict the pupil to open the angle.
b. Draw fluid from the eye into vascular circulation.
c. Decrease production of aqueous humor.
d. Increase outflow of aqueous humor. / assess / Understand
apply / 0.558 / 0.3
8. When administering Timolol (timoptic) eye gtts, it is important for the nurse to do, or educate the patient to do this after administering:
a. Assess heart rate before administering
b. Maintain pressure over the lacrimal sac to prevent systemic absorption
c. Administer at bedtime to decrease side effects
d. a & b / assess / Understand
apply / 0.766 / 0.2
9. The nurse is caring for a patient with conjunctivitis of the left eye who
has Sulfacetamide eye drops prescribed for use in the affected eye. The nurse explains that to help prevent the spread of infection, the patient should:
a. Apply an occlusive dressing to the affected eye
b. Avoid touching the eyes and wash hands frequently
c. Use the eye drops in both eyes as a prophylactic measure
d. Apply corticosteroid ointment to the right eye to decrease the risk of inflammation / implement / Understand
apply / 1.000 / 0.0
10. A patient is prepared for discharge following outpatient cataract surgery. To evaluate
whether the patient understands the postoperative regimen and procedures, the nurse asks the
patient:
a. To use the 0 to 10 pain scale to rate eye pain
b. To demonstrate administration of prescribed eye drops
c. To state how good the vision is in the operative eye
d. Why staying on bed rest for 24 hours is needed / Implement / Understand
apply / 0.935 / 0.0
11. A patient who had cataract extraction and intraocular lens implantation the previous
day calls the eye clinic and gives the nurse the following information. Which information is of
most concern to the nurse?
a. The patient has rated their eye pain at a 5 (on a 0-10 scale)
b. The patient complains that their vision has not improved tremendously
c. The patient has poor depth perception when wearing an eye patch
d. The patient has questions about the ordered eye drops / Assess / Understand
Apply
evaluate / 0.740 / 0.5
12. . A patient who has heart failure and has been receiving large doses if IV furosemide
(Lasix) tells the nurse, “I cannot hear very well. My ears are ringing” The most appropriate action
by the nurse is to
a. Arrange for the patient to have a hearing test
b. Withhold the ordered dose of furosemide and notify the physician
c. Tell the patient that these symptoms are temporary
d. Add the nursing diagnosis of disturbed auditory perception related to ototoxicity to the
patient’s care plan / assess / Understand
apply / 0.779 / 0.3
13. 1120-XI-9 A patient with Meniere’s disease is admitted with vertigo, nausea, and vomiting. Which
nursing intervention will be included in the care plan?
a. Encourage oral fluids to 3000mL daily
b. Change the patient’s position every 2 hours
c. Keep the head of the bed elevated 15 degrees
d. Keep the patient’s room darkened / implementation / Understand
apply / 0.883 / 0.3
14. The most appropriate nursing action for a patient with epistaxis is:
a. Decrease exposure to allergens.
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 / implement / Understand
apply / 0.805 / 0.2
15. The use of a hearing aid is most effective for which of the following conditions?
a. Conductive hearing loss
b. Serous otitis media
c. Tinnitis
d. Sensorineural hearing loss / assess / Understand
apply / 0.935 / 0.0
16 The patient you are caring for has dysarthria. Which nursing action is most
appropriate?
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.
/ Assess
implement / Understand
apply / 0.701 / 0.5
17. The daughter of a patient admitted unconscious to the ER with a possible stroke
reports that her mother has a history of hypertension that she does not manage well. She has
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 / assess / Understand
apply / 0.831 / 0.3
18. A client has been admitted to the hospital after having a stroke. What predisposing
factor in this patient’s history places this client at risk for an embolic stroke?
a. A history of hypertension
b. A history of psychotropic drug use
c. A history of atrial fibrillation
d. A history of cerebral aneurysm / assess / Understand
apply / 0.857 / 0.3
19. The nurse identifies the nursing diagnosis of impaired verbal communication for a patient with expressive aphasia. An appropriate nursing intervention to help the patient
communicate is to:
a. Ask simple questions that the patient can answer with “yes” or “no.”
b. Develop a list of words that the patient can read and practice reciting.
c. Have the patient practice facial and tongue exercises to improve motor control necessary
for speech.
d. Prevent embarrassing the patient by changing the subject if the patient does not respond
in a timely manner / Assess
Implement / Understand
apply / 0.961 / 0.1
20. A patient with a stroke has progressive development of neurologic deficits with increasing weakness and decreased level of consciousness (LOC). The nursing priority that is most relevant to guide your care at this time will be:
a. Risk for impaired skin integrity r/t immobility
b. Disturbed sensory perception r/t brain injury
c. Risk for aspiration r/t inability to protect airway
d. Impaired physical mobility r/t weakness / Assess
implement / Understand
apply / 0.468 / 0.4

KEY:

Cognitive Level:
Remembering
Understanding
Applying
Analyzing
Evaluating
Creating / Item Discrimination = how well an item distinguishes between high and low scoring students.
· 0 is OK if it’s info that everyone absolutely needs to know, i.e. key content.
· .2 to .3 is desirable for most
· .4 or higher is OK for just a few questions. If all were .4, most of our students would fail the test.
· 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.

FINAL EXAM

ALTERATION IN SENSORY STIMULATION (5)
1. 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:
a. Macular degeneration
b. Cataracts
c. Conjunctivitis
d. Glaucoma / assess / Understand / 0.937 / 0.2
2. Your patient has a history of vision problems including a gradual loss of visual acuity and generalized blurry vision. The patient has no pain in the eyes. These symptoms are most usually associated with:
a. Macular degeneration
b. Conjunctivitis
c. Myopia
d. Cataracts / assess / Understand
apply / 0.734 / 0.0
3. Your patient has two different eye drops ordered for a new diagnosis of glaucoma. How long should you teach to wait between successive eye drops in the same eye to achieve adequate eye drop drug retention and absorption?
a. 1 minute
b. 5 minutes
c. c.30 minutes
d. d.60 minutes / implement / Understand
apply / 0.835 / 0.0
4. A patient admitted with a stroke is coming to your unit from the emergency department. What assessment data is indicative of a stroke?
a. Facial droop
b. Dysarthria
c. hemiparesis
d. a & b
e. a, b, c / assess / Understand
apply / 0.949 / 0.1
5. Your patient who suffered an ischemic stroke now has disturbed visual perception (visual field cut). What intervention will be required when caring for this patient?
a. The patient should be approached on the side where visual perception is intact.
b. Attention to the affected side should be minimized.
c. The patient should avoid repetitious turning of his head in the direction of the defective visual field in order to minimize dizziness.
d. The patient should be approached on the opposite side of where the visual perception is intact in order to increase perception and vision. / implement / Understand
apply / 0.848 / 0.1