NCLEX REVIEW (HESI/SAUNDERS)
MED-SURG
Thexnursexisxperformingxanxadmissionxassessmentxonxaxclientxwithxaxdiagnosisxofxdetach
edxretina.xWhichxsignxorxsymptomxisxassociatedxwithxthisxeyexdisorder?x-
xans✔✔Axsensexofxaxcurtainxfallingxacrossxthexfieldxofxvision
Thexnursexisxperformingxanxotoscopicxexaminationxonxaxclientxwithxmastoiditis.xOnxexami
nationxofxthextympanicxmembrane,xwhichxfindingxshouldxthexnursexexpectxtoxobserve?x-
xans✔✔Axred,xdull,xthick,xandximmobilextympanicxmembrane
Otoscopicxexaminationxinxaxclientxwithxmastoiditisxrevealsxaxred,xdull,xthick,xandximmobilex
tympanicxmembrane,xwithxorxwithoutxperforation.xPostauricularxlymphxnodesxarextenderxa
ndxenlarged.xClientsxalsoxhavexaxlow-
gradexfever,xmalaise,xanorexia,xswellingxbehindxthexear,xandxpainxwithxminimalxmovemen
txofxthexhead.
Axclientxisxdiagnosedxwithxaxdisorderxinvolvingxthexinnerxear.xWhichxisxthexmostxcommonxc
lientxcomplaintxassociatedxwithxaxdisorderxinvolvingxthisxpartxofxthexear?x-xans✔✔Tinnitus
Tinnitusxisxthexmostxcommonxcomplaintxofxclientsxwithxotologicalxdisorders,xespeciallyxdis
ordersxinvolvingxthexinnerxear.xSymptomsxofxtinnitusxrangexfromxmildxringingxinxthexear,xw
hichxcanxgoxunnoticedxduringxthexday,xtoxaxloudxroaringxinxthexear,xwhichxcanxinterferexwit
hxthexclient'sxthinkingxprocessxandxattentionxspan.
Thexnursexisxperformingxanxassessmentxonxaxclientxwithxaxsuspectedxdiagnosisxofx*catara
ct*.xWhichxclinicalxmanifestationxshouldxthexnursexexpectxtoxnotexinxthexearlyxstagesxofxcat
aractxformation?x-xans✔✔*Blurredxvision*x
Axgradual,xpainlessxblurringxofxcentralxvisionxisxthexchiefxclinicalxmanifestationxofxaxcatara
ct.xEarlyxsymptomsxincludexslightlyxblurredxvisionxandxaxdecreasexinxcolorxperception.
Thexnursexisxpreparingxaxteachingxplanxforxaxclientxwhoxhadxaxcataractxextractionxwithxintr
aocularximplantation.xWhichxhomexcarexmeasuresxshouldxthexnursexincludexinxthexplan?
xSelectxallxthatxapply.x-xans✔✔avoidxactivitiesxthatxrequirexbendingxover.
Takexacetaminophenxforxminorxeyexdiscomfort.
, x
Placexanxeyexshieldxonxthexsurgicalxeyexatxbedtime.
Contactxthexsurgeonxifxaxdecreasexinxvisualxacuityxoccurs.
Followingxeyexsurgery,xsomexscratchinessxandxmildxeyexdiscomfortxmayxoccurxinxthexoper
ativexeyexandxusuallyxisxrelievedxbyxmildxanalgesics.xIfxthexeyexpainxbecomesxsevere,xthex
clientxshouldxnotifyxthexsurgeonxbecausexthisxmayxindicatexhemorrhage,xinfection,xorxincr
easedxintraocularxpressurex(IOP).xThexnursexalsoxwouldxinstructxthexclientxtoxnotifyxthexsu
rgeonxofxincreasedxpurulentxdrainage,xincreasedxredness,xorxanyxdecreasexinxvisualxacuit
y.xThexclientxisxinstructedxtoxplacexanxeyexshieldxoverxthexoperativexeyexatxbedtimextoxprot
ectxthexeyexfromxinjuryxduringxsleepxandxtoxavoidxactivitiesxthatxincreasexIOP,xsuchxasxben
dingxover.
Tonometryxisxaxmethodxofxmeasuringxintraocularxfluidxpressure.x-
xans✔✔Pressuresxbetweenx10xandx21xmmxHgxarexconsideredxwithinxthexnormalxrange.x
However,xIOPxisxslightlyxhigherxinxthexmorning.xTherefore,xthexinitialxactionxisxtoxcheckxthe
xtimexthextestxwasxperformed.
Thexnursexisxcaringxforxaxclientxfollowingxcraniotomyxforxremovalxofxanxacousticxneuroma.x
Assessmentxofxwhichxcranialxnervexwouldxidentifyxaxcomplicationxspecificallyxassociatedx
withxthisxsurgery?x-xans✔✔CranialxnervexVII,xfacialxnerve
nxacousticxneuromax(orxvestibularxschwannoma)xisxaxunilateralxbenignxtumorxthatxoccursx
wherexthexvestibulocochlearxorxacousticxnervex(cranialxnervexVIII)xentersxthexinternalxaudi
toryxcanal.xItxisximportantxthatxanxearlyxdiagnosisxbexmadexbecausexthextumorxcanxcompr
essxthextrigeminalxandxfacialxnervesxandxarteriesxwithinxthexinternalxauditoryxcanal.xTreat
mentxforxacousticxneuromaxisxsurgicalxremovalxviaxaxcraniotomy.xAssessmentxofxthextrige
minalxandxfacialxnervesxisximportant.xExtremexcarexisxtakenxtoxpreservexremainingxhearin
gxandxpreservexthexfunctionxofxthexfacialxnerve.xAcousticxneuromasxrarelyxrecurxfollowingx
surgicalxremoval.
Thexnursexplacesxanxeyexpatchxoverxthexclient'sxaffectedxeyextoxreducexeyexmovementxw/
xGLAUCOMA.xSomexclientsxmayxneedxbilateralxpatching.xDependingxonxthexlocationxandx
sizexofxthexretinalxbreak,xactivityxrestrictionsxmayxbexneededximmediately.xThesexrestrictio
nsxarexnecessaryxtoxpreventxfurtherxtearingxorxdetachmentxandxtoxpromotexdrainagexofxan
yxsubretinalxfluid.xTherefore,xreadingxandxwatchingxtelevisionxarexnotxallowed.xThexclient's
xpositionxisxprescribedxbyxthexhealthxcarexprovider;xnormally,xthex.x-
xans✔✔prescriptionxisxtoxliexflat.
openxanglexglaucomax-xans✔✔tunnelxvision,x
cuppingxofxopticxdisc.
xTx-xtimololxdrops,
xmaybexlaserxtrabeculoplasty,xmaybexsurgicalxtrabeculectomy
MED-SURG
Thexnursexisxperformingxanxadmissionxassessmentxonxaxclientxwithxaxdiagnosisxofxdetach
edxretina.xWhichxsignxorxsymptomxisxassociatedxwithxthisxeyexdisorder?x-
xans✔✔Axsensexofxaxcurtainxfallingxacrossxthexfieldxofxvision
Thexnursexisxperformingxanxotoscopicxexaminationxonxaxclientxwithxmastoiditis.xOnxexami
nationxofxthextympanicxmembrane,xwhichxfindingxshouldxthexnursexexpectxtoxobserve?x-
xans✔✔Axred,xdull,xthick,xandximmobilextympanicxmembrane
Otoscopicxexaminationxinxaxclientxwithxmastoiditisxrevealsxaxred,xdull,xthick,xandximmobilex
tympanicxmembrane,xwithxorxwithoutxperforation.xPostauricularxlymphxnodesxarextenderxa
ndxenlarged.xClientsxalsoxhavexaxlow-
gradexfever,xmalaise,xanorexia,xswellingxbehindxthexear,xandxpainxwithxminimalxmovemen
txofxthexhead.
Axclientxisxdiagnosedxwithxaxdisorderxinvolvingxthexinnerxear.xWhichxisxthexmostxcommonxc
lientxcomplaintxassociatedxwithxaxdisorderxinvolvingxthisxpartxofxthexear?x-xans✔✔Tinnitus
Tinnitusxisxthexmostxcommonxcomplaintxofxclientsxwithxotologicalxdisorders,xespeciallyxdis
ordersxinvolvingxthexinnerxear.xSymptomsxofxtinnitusxrangexfromxmildxringingxinxthexear,xw
hichxcanxgoxunnoticedxduringxthexday,xtoxaxloudxroaringxinxthexear,xwhichxcanxinterferexwit
hxthexclient'sxthinkingxprocessxandxattentionxspan.
Thexnursexisxperformingxanxassessmentxonxaxclientxwithxaxsuspectedxdiagnosisxofx*catara
ct*.xWhichxclinicalxmanifestationxshouldxthexnursexexpectxtoxnotexinxthexearlyxstagesxofxcat
aractxformation?x-xans✔✔*Blurredxvision*x
Axgradual,xpainlessxblurringxofxcentralxvisionxisxthexchiefxclinicalxmanifestationxofxaxcatara
ct.xEarlyxsymptomsxincludexslightlyxblurredxvisionxandxaxdecreasexinxcolorxperception.
Thexnursexisxpreparingxaxteachingxplanxforxaxclientxwhoxhadxaxcataractxextractionxwithxintr
aocularximplantation.xWhichxhomexcarexmeasuresxshouldxthexnursexincludexinxthexplan?
xSelectxallxthatxapply.x-xans✔✔avoidxactivitiesxthatxrequirexbendingxover.
Takexacetaminophenxforxminorxeyexdiscomfort.
, x
Placexanxeyexshieldxonxthexsurgicalxeyexatxbedtime.
Contactxthexsurgeonxifxaxdecreasexinxvisualxacuityxoccurs.
Followingxeyexsurgery,xsomexscratchinessxandxmildxeyexdiscomfortxmayxoccurxinxthexoper
ativexeyexandxusuallyxisxrelievedxbyxmildxanalgesics.xIfxthexeyexpainxbecomesxsevere,xthex
clientxshouldxnotifyxthexsurgeonxbecausexthisxmayxindicatexhemorrhage,xinfection,xorxincr
easedxintraocularxpressurex(IOP).xThexnursexalsoxwouldxinstructxthexclientxtoxnotifyxthexsu
rgeonxofxincreasedxpurulentxdrainage,xincreasedxredness,xorxanyxdecreasexinxvisualxacuit
y.xThexclientxisxinstructedxtoxplacexanxeyexshieldxoverxthexoperativexeyexatxbedtimextoxprot
ectxthexeyexfromxinjuryxduringxsleepxandxtoxavoidxactivitiesxthatxincreasexIOP,xsuchxasxben
dingxover.
Tonometryxisxaxmethodxofxmeasuringxintraocularxfluidxpressure.x-
xans✔✔Pressuresxbetweenx10xandx21xmmxHgxarexconsideredxwithinxthexnormalxrange.x
However,xIOPxisxslightlyxhigherxinxthexmorning.xTherefore,xthexinitialxactionxisxtoxcheckxthe
xtimexthextestxwasxperformed.
Thexnursexisxcaringxforxaxclientxfollowingxcraniotomyxforxremovalxofxanxacousticxneuroma.x
Assessmentxofxwhichxcranialxnervexwouldxidentifyxaxcomplicationxspecificallyxassociatedx
withxthisxsurgery?x-xans✔✔CranialxnervexVII,xfacialxnerve
nxacousticxneuromax(orxvestibularxschwannoma)xisxaxunilateralxbenignxtumorxthatxoccursx
wherexthexvestibulocochlearxorxacousticxnervex(cranialxnervexVIII)xentersxthexinternalxaudi
toryxcanal.xItxisximportantxthatxanxearlyxdiagnosisxbexmadexbecausexthextumorxcanxcompr
essxthextrigeminalxandxfacialxnervesxandxarteriesxwithinxthexinternalxauditoryxcanal.xTreat
mentxforxacousticxneuromaxisxsurgicalxremovalxviaxaxcraniotomy.xAssessmentxofxthextrige
minalxandxfacialxnervesxisximportant.xExtremexcarexisxtakenxtoxpreservexremainingxhearin
gxandxpreservexthexfunctionxofxthexfacialxnerve.xAcousticxneuromasxrarelyxrecurxfollowingx
surgicalxremoval.
Thexnursexplacesxanxeyexpatchxoverxthexclient'sxaffectedxeyextoxreducexeyexmovementxw/
xGLAUCOMA.xSomexclientsxmayxneedxbilateralxpatching.xDependingxonxthexlocationxandx
sizexofxthexretinalxbreak,xactivityxrestrictionsxmayxbexneededximmediately.xThesexrestrictio
nsxarexnecessaryxtoxpreventxfurtherxtearingxorxdetachmentxandxtoxpromotexdrainagexofxan
yxsubretinalxfluid.xTherefore,xreadingxandxwatchingxtelevisionxarexnotxallowed.xThexclient's
xpositionxisxprescribedxbyxthexhealthxcarexprovider;xnormally,xthex.x-
xans✔✔prescriptionxisxtoxliexflat.
openxanglexglaucomax-xans✔✔tunnelxvision,x
cuppingxofxopticxdisc.
xTx-xtimololxdrops,
xmaybexlaserxtrabeculoplasty,xmaybexsurgicalxtrabeculectomy
