NCLEX-PN
Sensory NCLEX Questions Questions
Extract:
Question 1 of 5
The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to document in the client's chart?
Correct Answer: C
Rationale: Ringing in the ears is tinnitus, the appropriate term to document. Vertigo, otorrhea, and presbycusis (age-related hearing loss) are distinct symptoms.
Question 2 of 5
A 50-year-old client is admitted with the diagnosis of open-angle glaucoma. Which of the following symptoms would the nurse expect the client to have?
Correct Answer: D
Rationale: Open-angle glaucoma is characterized by halos around objects due to increased intraocular pressure, not severe pain or headaches.
Question 3 of 5
The male client diagnosed with type 2 diabetes mellitus tells the nurse he has begun to see yellow spots. Which interventions should the nurse implement? List in order of priority.
Order the Items
Source Container
Correct Answer: A,E,C,B,D
Rationale: 1) Notify HCP (urgent for possible diabetic retinopathy); 2) Determine spot location (assess severity); 3) Amsler grid (evaluate central vision); 4) Check HbA1c (assess control); 5) Teach glucose control (long-term management).
Question 4 of 5
Which assessment technique should the nurse use to assess the client's optic nerve?
Correct Answer: C
Rationale: The optic nerve (cranial nerve II) is assessed by visual acuity tests like the Snellen chart. Smells (olfactory), taste (facial/glossopharyngeal), and uvula movement (vagus) involve other nerves.
Question 5 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.