The nurse is visiting the day care center for routine assessment ...

[mmm]

The nurse is visiting the day care center for routine assessment of the children. After spending time with the children in one of the playrooms, the nurse suspects that a child has a visual deficit as a result of observing:
 
  1. Poor balance and gait
  2. An increase in weight
  3. Sitting and rocking back and forth
  4. A failure to respond when touched

Question 2

A client has been in the intensive care unit for 4 days and has begun to show signs of restlessness and anxiety even though the client has been reassured that his or her condition is improving and discharge to the unit will be occurring soon.
 
  The cause of the client's emotional state is a result of:
  1. Fear of death
  2. Social isolation
  3. Sensory overload
  4. Anxiety disorder

[jgranad15]

Answer to Question 1

ANS: 3
Behaviors of children indicating a possible visual deficit include self-stimulation such as eye rub-bing, body rocking, sniffing or smelling, and arm twirling. Poor balance and gait may indicate an impairment of position sense in the adult. A weight change may indicate a deficit in taste in the adult. Failure to respond to touch may indicate a touch deficit in the adult.

Answer to Question 2

ANS: 3
The acutely ill client easily falls victim to sensory overload. The client in constant pain or who undergoes frequent monitoring of vital signs or who has irritation from drainage tubes is at risk.

[mmm]

TYSM

[ebonylittles]

Thanks for the timely response, appreciate it