Page 1971 - Saunders Comprehensive Review For NCLEX-RN

redness, or any decrease in visual acuity. The client is instructed to place an eye
shield over the operative eye at bedtime to protect the eye from injury during sleep
and to avoid activities that increase IOP, such as bending over.
Test-Taking Strategy: Focus on the subject, postoperative care following eye
surgery. Recalling that the eye needs to be protected and that increased IOP is a
concern will assist in determining the home care measures to be included in the plan.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Teaching and Learning
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Cataracts
Priority Concepts: Client Education; Safety
Reference: Lewis et al. (2017), p. 376.

688. Answer: 2

Rationale: Tonometry is a method of measuring intraocular fluid pressure.
Pressures between 10 and 21 mm Hg are considered within the normal range.
However, IOP is slightly higher in the morning. Therefore, the initial action is to
check the time the test was performed. Normal saline drops are not a specific
treatment for glaucoma. It is not necessary to contact the PHCP as an initial action.
Flat positions may increase the pressure.
Test-Taking Strategy: Focus on the subject, normal IOP, and note the strategic
word, initial. Remember that normal IOP is between 10 and 21 mm Hg and the
pressure may be higher in the morning.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Eye
Health Problem: Adult Health: Eye: Glaucoma
Priority Concepts: Clinical Judgment; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), p. 965.

689. Answer: 4

Rationale: An acoustic neuroma (or vestibular schwannoma) is a unilateral benign
tumor that occurs where the vestibulocochlear or acoustic nerve (cranial nerve VIII)
enters the internal auditory canal. It is important that an early diagnosis be made,
because the tumor can compress the trigeminal and facial nerves and arteries within
the internal auditory canal. Treatment for acoustic neuroma is surgical removal via a
craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme
care is taken to preserve remaining hearing and preserve the function of the facial
nerve. Acoustic neuromas rarely recur following surgical removal.
Test-Taking Strategy: Focus on the subject, a complication following surgery.
Think about the anatomical location of an acoustic neuroma and the nerves that the
neuroma can compress to direct you to the correct option.
Level of Cognitive Ability: Analyzing

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