NCLEX-PN
Sensory NCLEX Questions Questions
Extract:
Question 1 of 5
A young man was swimming at the beach when an exceptionally large wave caused him to be drawn under the water. His family members found him in the water and pulled him ashore. He states that he heard something snap in his neck. When a nurse arrives, he is conscious and lying on his back. He states that he has no pain. He is unable to move his legs. How should he be transported?
Correct Answer: B
Rationale: A suspected neck injury requires immobilization with a neck collar and supine positioning on a backboard to prevent further spinal cord damage.
Question 2 of 5
The nurse is concerned that the client in a long-term care facility is experiencing retinal detachment. Which intervention should the nurse implement first?
Correct Answer: C
Rationale: The nurse should contact the HCP and secure an ophthalmological evaluation promptly. Flushing the eye and applying a pressure bandage may cause further injury and delay treatment. Applying an eye shield and analgesic or patching both eyes delays securing treatment.
Question 3 of 5
The nurse is caring for a client diagnosed with a cerebrovascular accident (CVA). Which assessment information should the nurse determine first when placing the client in the assigned room?
Correct Answer: A
Rationale: Homonymous hemianopia (loss of half the visual field) from a CVA affects safety and orientation, requiring immediate assessment. Bed preference, dietary setup, and PT consults are secondary.
Question 4 of 5
Which assessment technique should the nurse implement when assessing the client's cranial nerves for vibration?
Correct Answer: B
Rationale: Placing a tuning fork on the big toe assesses vibration sense (via dorsal column pathways), not cranial nerves directly, but is the correct technique. Other options assess different sensations.
Question 5 of 5
The client is postoperative retinal detachment surgery, and gas tamponade was used to flatten the retina. Which intervention should the nurse implement first?
Correct Answer: B
Rationale: Positioning as prescribed (e.g., face-down) is critical to maintain gas tamponade efficacy and retinal reattachment. Teaching, assessment, and follow-up are secondary.