Page 1972 - Saunders Comprehensive Review For NCLEX-RN

Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Adult Health: Ear
Health Problem: Adult Health: Ear: Hearing Loss
Priority Concepts: Clinical Judgment; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), pp. 951, 996.

690. Answer: 3

Rationale: Presbycusis is a type of hearing loss that occurs with aging. Presbycusis
is a gradual sensorineural loss caused by nerve degeneration in the inner ear or
auditory nerve. When communicating with a client with this condition, the nurse
should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to
speak loudly, mumble or slur words, or speak into the client’s affected ear.
Test-Taking Strategy: Focus on the subject, presbycusis and the effective method
to communicate. Visualize each of the communication techniques to direct you to the
correct option.
Level of Cognitive Ability: Applying
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Implementation
Content Area: Adult Health: Ear
Health Problem: Adult Health: Ear: Hearing Loss
Priority Concepts: Communication; Sensory Perception
Reference: Ignatavicius, Workman, Rebar (2018), pp. 997-998.

691. Answer: 2

Rationale: The nurse instructs the client to make slow head movements to prevent
worsening of the vertigo. Dietary changes such as salt and fluid restrictions that
reduce the amount of endolymphatic fluid are sometimes prescribed. Lying still and
watching television will not control vertigo.
Test-Taking Strategy: Focus on the subject, preventing vertigo. Note the
relationship between vertigo and avoiding sudden head movements in the correct
option.
Level of Cognitive Ability: Applying
Client Needs: Safe and Effective Care Environment
Integrated Process: Teaching and Learning
Content Area: Adult Health: Ear
Health Problem: Adult Health: Ear: Vertigo/Tinnitus
Priority Concepts: Client Education; Safety
Reference: Ignatavicius, Workman, Rebar (2018), pp. 995-996.

692. Answer: 1

Rationale: Visual acuity is assessed in 1 eye at a time, and then in both eyes
together, with the client comfortably standing or sitting. The right eye is tested with
the left eye covered; then the left eye is tested with the right eye covered. Both eyes

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