NCLEX Questions on Sensory Perception

Extract:

Question 1 of 5

An adult man fell off a ladder and hit his head and lost consciousness. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. The nursing care plan will most likely include which of the following?

Correct Answer: A

Rationale: Elevating the head of the bed 15 to 30 degrees promotes gravity drainage of fluid and reduces cerebral edema. Coughing, forcing fluids, and chest physical therapy may increase intracranial pressure and are contraindicated.

Question 2 of 5

When planning care for a woman with myasthenia gravis, the nurse asks her what time of day she feels strongest. The nurse would expect which of the following replies?

A. I can wash up and comb my hair before breakfast because I feel best in the morning.' B. I only feel good for about an hour after I take my medication.' C. I feel strongest in the evening, so I would prefer to take a shower before bedtime.' D. I feel best after lunch after I've been moving around a little.'

Correct Answer: A

Rationale: Muscle strength in myasthenia gravis is typically best in the morning, with weakness worsening throughout the day.

Question 3 of 5

The elderly client has undergone a right-eye cataract removal with an intraocular implant. Which discharge instructions should the nurse teach the client?

A. Have the client demonstrate placing the otic drops in the ear. B. Teach the client to instill the eyedrops as prescribed. C. Remind the client to keep the lights in the home low at all times. D. Encourage the client to sleep on two pillows at night.

Correct Answer: B

Rationale: Instilling prescribed eyedrops (e.g., antibiotics, steroids) prevents infection and inflammation post-cataract surgery. Otic drops are irrelevant, low lights are unnecessary, and elevation is not standard.

Question 4 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:

A. check for bladder distention. B. place him in the Trendelenburg position. C. administer PRN pain medication. D. position him on his left side.

Correct Answer: A

Rationale: Symptoms suggest autonomic dysreflexia, often triggered by bladder distention, requiring immediate assessment and intervention.

Question 5 of 5

The client recently diagnosed with glaucoma tells the nurse, 'I'm having difficulty remembering to insert my eye drops. I don't have any pain or vision changes when I forget them.' Which statement is the best response?

A. You should be diligent in inserting the eye drops; if not, then you will need surgery. B. You wouldn't have pain, but untreated glaucoma will eventually lead to vision loss. C. Tell me about your day; planning a time with a daily activity often helps as a reminder. D. I know this must be hard for you; not everyone is able to remember everything.

Correct Answer: C

Rationale: This is a broad opening statement and can assist the client to problem-solve an activity that could serve as a reminder to take the eye drops. The other statements are either belittling, partially incorrect, or do not help with adherence.

NCLEX Questions on Sensory Perception | Nurselytic

Nurselytic

NCLEX-PN

NCLEX-PN