Page 1967 - Saunders Comprehensive Review For NCLEX-RN

Health Problem: Adult Health: Eye: Cataracts
Priority Concepts: Clinical Judgment; Pain
Reference: Ignatavicius, Workman, Rebar (2018), p. 971.

677. Answer: 3

Rationale: The administration of eye drops is a critical component of the
treatment plan for the client with glaucoma. The client needs to be instructed that
medications will need to be taken for the rest of her or his life. Options 1, 2, and 4 are
not accurate instructions.
Test-Taking Strategy: Focus on the subject, client teaching for glaucoma.
Recalling that medications are an integral component of the treatment plan will
assist in directing you to the correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Glaucoma
Priority Concepts: Client Education; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), p. 975.

678. Answer: 4

Rationale: A characteristic manifestation of retinal detachment described by the
client is the feeling that a shadow or curtain is falling across the field of vision. No
pain is associated with detachment of the retina. Options 1 and 3 are not
characteristics of this problem. A retinal detachment is an ophthalmic emergency,
and even more so if visual acuity is still normal.
Test-Taking Strategy: Focus on the subject, manifestations of retinal detachment.
Thinking about the pathophysiology associated with this problem will direct you to
the correct option.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Retinal Detachment
Priority Concepts: Clinical Judgment; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), p. 979.

679. Answer: 4

Rationale: Otoscopic examination in a client with mastoiditis reveals a red, dull,
thick, and immobile tympanic membrane, with or without perforation. Postauricular
lymph nodes are tender and enlarged. Clients also have a low-grade fever, malaise,
anorexia, swelling behind the ear, and pain with minimal movement of the head.
Test-Taking Strategy: Focus on the subject, the assessment findings in mastoiditis.
Think about the pathophysiology associated with mastoiditis and remember that

1967