NCLEX-PN
Sensory NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is caring for a client admitted with Guillain-Barré syndrome. On day three of hospitalization, his muscle weakness worsens, and he is no longer able to stand with support. He is also having difficulty swallowing and talking. The priority in his nursing care plan should be to prevent which of the following?
Correct Answer: A
Rationale: Difficulty swallowing increases the risk of aspiration pneumonia, making it the priority in Guillain-Barré syndrome.
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
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 4 of 5
The nurse is caring for multiple older adult clients with age-related visual changes. Which intervention should the nurse implement?
Correct Answer: C
Rationale: The nurse should provide a magnifying device for reading to enlarge words, making them easier to read. Normal-sized fonts, low-intensity lamps, and blended colors are less effective for visual changes.
Question 5 of 5
The nurse is assessing the older adult client with otosclerosis. Which diagnostic characteristics should the nurse associate with otosclerosis?
Correct Answer: A
Rationale: Otosclerosis impairs the air conduction of sound waves; therefore, bone conduction is typically greater than air conduction. Hearing aids and surgical restoration (stapedectomy) are effective, and progressive hearing loss is detected by serial audiograms.