NCLEX-PN
Sensory NCLEX Questions Questions
Extract:
Question 1 of 5
The nurse is caring for the client with macular degeneration. Which illustration should the nurse associate with the field disturbance seen by the client?
Correct Answer: B
Rationale: Distorted central vision as seen in illustration 2 is characteristic of macular degeneration. The macula is the area of the fundus responsible for central vision. When the cells in the macula have been damaged, central vision is impaired. Illustration 1 shows glaucoma, 3 shows normal vision, and 4 shows blurred vision from various conditions.
Question 2 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 3 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 4 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.
Question 5 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).