NCLEX-PN
NCLEX Questions on Sensory Perception Questions
Extract:
Question 1 of 5
A client who is recovering from a spinal cord injury complains of blurred vision and a severe headache. His blood pressure is 210/140. The most appropriate initial action for the nurse to take is to:
Correct Answer: A
Rationale: Symptoms suggest autonomic dysreflexia, often triggered by bladder distention, requiring immediate assessment and intervention.
Question 2 of 5
During an assessment, the nurse covers the client's right eye and then observes a shift in the client's gaze after the eye is uncovered. Which conclusion should the nurse make about the results of the test?
Correct Answer: D
Rationale: Covering and then uncovering the client's eye and then observing for a shift in the client's gaze is the cover-uncover test used to detect weakness in the extraocular muscles. Lens opacity is detected by direct observation. Stroking the eyelashes will evoke the blink reflex. The intraocular pressure is measured by tonometry.
Question 3 of 5
The client diagnosed with chronic otitis media is scheduled for a mastoidectomy. Which discharge teaching should the nurse discuss with the client?
Correct Answer: D
Rationale: Keeping the ear dry for six weeks prevents infection post-mastoidectomy. Blowing the nose closed increases pressure, hearing loss is not guaranteed, and ophthalmic drops are incorrect.
Question 4 of 5
The nurse reviews the chart of the client diagnosed with closed-angle glaucoma. Which documented finding should the nurse question with the HCP?
Correct Answer: C
Rationale: Closed-angle glaucoma causes an increased, not normal, intraocular pressure. This documentation finding should be questioned. Sudden eye pain, reduced central visual acuity, and nausea and vomiting are consistent with closed-angle glaucoma.
Question 5 of 5
The client tells the nurse about being diagnosed with 'wet type' macular degeneration. Which finding should the nurse expect to observe when examining the client's eyes using an ophthalmoscope?
Correct Answer: A
Rationale: The 'wet type' of macular degeneration results from the growth of abnormal blood vessels in the macula. The blood vessels often leak fluid and blood. Atrophy occurs in dry macular degeneration, cloudy lens indicates cataract, and corneal arcus is a normal finding in older clients.