Page 1968 - Saunders Comprehensive Review For NCLEX-RN

mastoiditis reveals a red, dull, thick, and immobile tympanic membrane.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Ear
Health Problem: Adult Health: Ear: Inflammatory/Infections/Structural Problems
Priority Concepts: Infection; Inflammation
Reference: Lewis et al. (2017), pp. 384-385.

680. Answer: 2

Rationale: Tinnitus is the most common complaint of clients with otological
problems, especially problems involving the inner ear. Symptoms of tinnitus range
from mild ringing in the ear, which can go unnoticed during the day, to a loud
roaring in the ear, which can interfere with the client’s thinking process and
attention span. Options 1, 3, and 4 are not associated specifically with problems of
the inner ear.
Test-Taking Strategy: Note the strategic word, most. Recalling the anatomy and
the function of the inner ear 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: Ear
Health Problem: Adult Health: Ear: Vertigo/Tinnitus
Priority Concepts: Clinical Judgment; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), p. 995.

681. Answer: 4

Rationale: A gradual, painless blurring of central vision is the chief clinical
manifestation of a cataract. Early symptoms include slightly blurred vision and a
decrease in color perception. Options 1, 2, and 3 are not characteristics of a cataract.
Test-Taking Strategy: Note the strategic word, early. Remember the
pathophysiology related to cataract development. As a cataract develops, the lens of
the eye becomes opaque. This description will assist in directing 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: Cataracts
Priority Concepts: Clinical Judgment; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), p. 969.

682. Answer: 2

Rationale: A hyphema is the presence of blood in the anterior chamber. Hyphema

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