Page 1964 - Saunders Comprehensive Review For NCLEX-RN

3. A yellow discoloration of the sclera
4. A sense of a curtain falling across the field of vision
679. The nurse is performing an otoscopic examination on a client with
mastoiditis. On examination of the tympanic membrane, which finding
should the nurse expect to observe?
1. A pink-colored tympanic membrane
2. A pearly colored tympanic membrane
3. A transparent and clear tympanic membrane
4. A red, dull, thick, and immobile tympanic membrane
680. A client is diagnosed with a problem involving the inner ear. Which is the
most common client complaint associated with a problem involving this part
of the ear?
1. Pruritus
2. Tinnitus
3. Hearing loss
4. Burning in the ear
681. The nurse is performing an assessment on a client with a suspected diagnosis
of cataract. Which clinical manifestation should the nurse expect to note in
the early stages of cataract formation?
1. Diplopia
2. Eye pain
3. Floating spots
4. Blurred vision
682. A client arrives in the emergency department following an automobile crash.
The client’s forehead hit the steering wheel, and a hyphema is diagnosed.
The nurse should place the client in which position?
1. Flat in bed
2. A semi-Fowler’s position
3. Lateral on the affected side
4. Lateral on the unaffected side
683. The client sustains a contusion of the eyeball following a traumatic injury
with a blunt object. Which intervention should be initiated immediately?
1. Apply ice to the affected eye.
2. Irrigate the eye with cool water.
3. Notify the primary health care provider (PHCP).
4. Accompany the client to the emergency department.
684. A client arrives in the emergency department with a penetrating eye injury
from wood chips that occurred while cutting wood. The nurse assesses the
eye and notes a piece of wood protruding from the eye. What is the initial
nursing action?
1. Apply an eye patch.
2. Perform visual acuity tests.
3. Irrigate the eye with sterile saline.
4. Remove the piece of wood using a sterile eye clamp.
685. The nurse is caring for a client following enucleation to treat an ocular tumor
and notes the presence of bright red drainage on the dressing. Which action
should the nurse take at this time?
1. Document the finding.

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