NCLEX-PN
Sensory NCLEX Questions Questions
Extract:
Question 1 of 5
An adult man fell off a ladder and hit his head. His wife rushed to help him and found him unconscious. After regaining consciousness several minutes later, he was drowsy and had trouble staying awake. He is admitted to the hospital for evaluation. When the nurse enters the room, he is sleeping. While caring for the client, the nurse finds that his systolic blood pressure has increased, his pulse has decreased, and his temperature is slightly elevated. What does this suggest?
Correct Answer: C
Rationale: Increased systolic blood pressure, decreased pulse, and elevated temperature suggest increased intracranial pressure (Cushing's triad) post-head injury.
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 elderly client is complaining of abdominal discomfort. Which scientific rationale should the nurse remember when addressing an elderly client's perception of pain?
Correct Answer: C
Rationale: Age-related sensory decline reduces pain perception in the elderly, affecting reporting. Pain reaction varies, more medication is not standard, and the Wong scale is pediatric.
Question 4 of 5
The client with severely diminished vision has difficulty with visual discrimination. Which interventions should the nurse recommend to improve the client's sight in the home environment? Select all that apply.
Correct Answer: B,C,D
Rationale: Using black on white enhances readability. Velcro tabs on light switches aid location in low vision. Contrasting doorknob colors improve safety. Blending wall colors or matching dish and tablecloth colors worsens visual discrimination.
Question 5 of 5
The doctor orders a Tensilon test for a woman suspected of having myasthenia gravis. Which statement is true about this test?
Correct Answer: A
Rationale: A positive Tensilon test shows increased muscle strength within one minute, confirming myasthenia gravis, as Tensilon enhances acetylcholine activity.