NCLEX-PN
Sensory NCLEX Questions Questions
Extract:
Question 1 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 2 of 5
The nurse is caring for a client diagnosed with acute otitis media. Which signs/symptoms support this medical diagnosis?
Correct Answer: A
Rationale: Unilateral ear pain is a primary symptom of acute otitis media. Foul drainage suggests chronic infection, congestion is non-specific, and hearing loss is less common acutely.
Question 3 of 5
The client is receiving treatment with gentamicin ophthalmic solution for bacterial conjunctivitis. Which symptom, described by the client, indicates that the medication is ineffective?
Correct Answer: B
Rationale: Mucopurulent eye drainage, especially yellowish or greenish, is associated with bacterial conjunctivitis; continuing with eye drainage indicates gentamicin is ineffective in treating the infection. Eyestrain, twitching, and inability to read small print are not associated with an infectious process.
Question 4 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 5 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.