NCLEX-PN
Sensory NCLEX Questions Questions
Extract:
Question 1 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.
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 2 of 5
The nurse is assessing the client’s sensory system. Which assessment data indicate an abnormal stereognosis test?
Correct Answer: D
Rationale: Abnormal stereognosis is the inability to identify objects (e.g., a key) by touch with eyes closed, indicating parietal lobe dysfunction.
Toe movement, sharp/dull, and Babinski reflex test other functions.
Question 3 of 5
An adult is being treated with phenytoin (Dilantin) for a seizure disorder. Five days after starting the medication, he tells the nurse that his urine is reddish-brown in color. What action should the nurse take?
Correct Answer: A
Rationale: Phenytoin commonly causes reddish-brown urine, a benign side effect, so informing the client is appropriate. Testing or reporting is unnecessary unless other symptoms suggest a problem.
Question 4 of 5
The 60-year-old client notices a gradual decline in visual acuity and asks if it could be from a cataract. Which question will help determine whether a cataract is developing?
Correct Answer: A
Rationale: Asking about a change in the ability to perceive colors will help in determining cataract development. Cataract formation involves the lens of the eye becoming more opaque, thus decreasing the vibrancy of colors. Distorted central vision is a sign of macular degeneration. A darkened area in the center of the visual field is associated with macular degeneration. Seeing flashes of bright lights is associated with retinal detachment.
Question 5 of 5
Which ototoxic medication should the nurse recognize as potentially life altering or threatening to the client?
Correct Answer: B
Rationale: Aminoglycosides (e.g., gentamicin) are ototoxic, causing permanent hearing loss, which is life-altering. Calcium channel blockers, glucocorticoids, and loop diuretics are less ototoxic.