Nursing 220 - Exam 3 Questions with Detailed
Verified Answers
Ms. Small has sustained a brain attack (stroke/CVA). The nurse notes that the patient
is having difficulty placing her affected leg in the correct position when ambulating. This
is most likely due to which of the following?
A. Poor directions given to the patient by the physical therapist
B. The patient's lack of proprioception
C. Impaired blood flow to the affected leg
D. The patient's resistance to therapy Ans: B. The patient's lack of proprioception
Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so
tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse
is 110 beats/min, and his blood pressure is 140/70 mm Hg. Nursing actions should
include which of the following to address his sensory status?
A. Turn on the television or radio in his room so it will distract him.
B. Have the therapist ambulate the patient so he can walk off his anxiety.
C. Close the blinds, dim the lights, and ask the patient what other measures would
help him rest.
,D. Call the physician and obtain an order for an anti-anxiety medication for prn use.
Ans: C. Close the blinds, dim the lights, and ask the patient what other measures
would help him rest.
Timothy is hospitalized and in a coma following a traumatic brain injury. Nursing care
would include which of the following?
A. Identify yourself when you enter the room and tell him the day and time
B. Tape his eyelids closed securely to prevent the drying of the corneas.
C. Limit the family's involvement in care so there is more consistency.
D. Avoid touching the patient, because this will increase his irritability. Ans: A. Identify
yourself when you enter the room and tell him the day and time
Cleaning a patient's hearing aid is a nursing action that will have a positive effect on a
sensory deficit.
(T or F) Ans: True
anosmia Ans: loss of smell
Loss of hearing can put a patient at risk for social isolation.
(T or F) Ans: True
A patient must place his hand on the wall to keep his balance when walking. He leans
when sitting and has difficulty knowing when his body is vertical and sensing the
position of his body in space. Which type of receptor is probably involved?
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,1) Photoreceptors
2) Chemoreceptors
3) Proprioceptors
4) Thermoreceptors Ans: 3) Proprioceptors
Which medication might blunt a patient's perception of various kinds of stimuli?
1) Furosemide (Lasix)
2) Metoprolol (Lopressor)
3) Morphine sulfate
4) Metoclopramide (Reglan) Ans: 3) Morphine sulfate
A patient complains, "Everything tastes so bland. I add salt, pepper, and sugar to
everything just to make it so I can taste it." Which nutrient deficiency might be
responsible for his problem? Select all that apply.
1) Vitamin A
2) Vitamin B12
3) Iron
4) Zinc Ans: 2, 4
© Get it right 2025 Getaway - Stuvia US All rights reserved
, After sustaining an eye injury in a baseball game, a patient complains of blurred and
distorted vision. Which visual deficit is this patient most likely experiencing?
1) Macular degeneration
2) Astigmatism
3) Strabismus
4) Glaucoma Ans: 2) Astigmatism
A patient who has been unable to sleep for several nights has experienced a change in
mental status. He does not know what day it is, or where he is. His speech and
movements are slowed, and he seems dazed and stupefied. He cannot follow simple
directions such as, "Hold out your hand." Which nursing diagnosis is most appropriate
for this patient?
1) Chronic Confusion
2) Acute Confusion
3) Impaired Environmental Interpretation Syndrome
4) Impaired Memory Ans: 2) Acute Confusion
A patient in a nursing home is deaf and nearly blind. He is confined to bed most of the
time. Which of the following interventions would help to promote optimal sensory
function?
1) Keep the television on during waking hours.
2) Put colorful artwork on the walls.
© Get it right 2025 Getaway - Stuvia US All rights reserved
Verified Answers
Ms. Small has sustained a brain attack (stroke/CVA). The nurse notes that the patient
is having difficulty placing her affected leg in the correct position when ambulating. This
is most likely due to which of the following?
A. Poor directions given to the patient by the physical therapist
B. The patient's lack of proprioception
C. Impaired blood flow to the affected leg
D. The patient's resistance to therapy Ans: B. The patient's lack of proprioception
Mr. Arbor complains to the nurse that he is feeling anxious. He states, "I'm just so
tired of all these tests they are doing, and it's so noisy here at night." Mr. Arbor's pulse
is 110 beats/min, and his blood pressure is 140/70 mm Hg. Nursing actions should
include which of the following to address his sensory status?
A. Turn on the television or radio in his room so it will distract him.
B. Have the therapist ambulate the patient so he can walk off his anxiety.
C. Close the blinds, dim the lights, and ask the patient what other measures would
help him rest.
,D. Call the physician and obtain an order for an anti-anxiety medication for prn use.
Ans: C. Close the blinds, dim the lights, and ask the patient what other measures
would help him rest.
Timothy is hospitalized and in a coma following a traumatic brain injury. Nursing care
would include which of the following?
A. Identify yourself when you enter the room and tell him the day and time
B. Tape his eyelids closed securely to prevent the drying of the corneas.
C. Limit the family's involvement in care so there is more consistency.
D. Avoid touching the patient, because this will increase his irritability. Ans: A. Identify
yourself when you enter the room and tell him the day and time
Cleaning a patient's hearing aid is a nursing action that will have a positive effect on a
sensory deficit.
(T or F) Ans: True
anosmia Ans: loss of smell
Loss of hearing can put a patient at risk for social isolation.
(T or F) Ans: True
A patient must place his hand on the wall to keep his balance when walking. He leans
when sitting and has difficulty knowing when his body is vertical and sensing the
position of his body in space. Which type of receptor is probably involved?
© Get it right 2025 Getaway - Stuvia US All rights reserved
,1) Photoreceptors
2) Chemoreceptors
3) Proprioceptors
4) Thermoreceptors Ans: 3) Proprioceptors
Which medication might blunt a patient's perception of various kinds of stimuli?
1) Furosemide (Lasix)
2) Metoprolol (Lopressor)
3) Morphine sulfate
4) Metoclopramide (Reglan) Ans: 3) Morphine sulfate
A patient complains, "Everything tastes so bland. I add salt, pepper, and sugar to
everything just to make it so I can taste it." Which nutrient deficiency might be
responsible for his problem? Select all that apply.
1) Vitamin A
2) Vitamin B12
3) Iron
4) Zinc Ans: 2, 4
© Get it right 2025 Getaway - Stuvia US All rights reserved
, After sustaining an eye injury in a baseball game, a patient complains of blurred and
distorted vision. Which visual deficit is this patient most likely experiencing?
1) Macular degeneration
2) Astigmatism
3) Strabismus
4) Glaucoma Ans: 2) Astigmatism
A patient who has been unable to sleep for several nights has experienced a change in
mental status. He does not know what day it is, or where he is. His speech and
movements are slowed, and he seems dazed and stupefied. He cannot follow simple
directions such as, "Hold out your hand." Which nursing diagnosis is most appropriate
for this patient?
1) Chronic Confusion
2) Acute Confusion
3) Impaired Environmental Interpretation Syndrome
4) Impaired Memory Ans: 2) Acute Confusion
A patient in a nursing home is deaf and nearly blind. He is confined to bed most of the
time. Which of the following interventions would help to promote optimal sensory
function?
1) Keep the television on during waking hours.
2) Put colorful artwork on the walls.
© Get it right 2025 Getaway - Stuvia US All rights reserved
