A 16-year-old patient sustained a head injury while playing soccer. When performing a neurologic check, the nurse looks at each pupil to determine
the state of consciousness.
if the shape is regular.
whether one pupil is larger than the other.
if they have become smaller.
The Correct Answer is C
A. While pupil response can be an indicator of consciousness, the primary concern when assessing pupils is to check for signs of increased intracranial pressure, such as unequal pupil size.
B. The shape of the pupil is important to assess, but the concern here is typically more about the size and response to light, which can indicate a neurological issue.
C. Unequal pupil sizes (anisocoria) can indicate neurological problems, such as increased intracranial pressure or brain injury, and requires further evaluation.
D. Pupil size changes could indicate a variety of issues, but the focus should be on detecting unequal pupils, which can be a critical sign in head injury patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. This is because the patient's blood pressure of 98/66 mm Hg, while on the lower side, may be normal for them. It's important to compare it to their baseline to determine if there has been a significant change.
B. The blood pressure is within a normal range for an adult, so immediate notification of hypotension is not required.
C. This can be done after determining if there is a significant change from the baseline.
D. The pulse is not bradycardic (it is within a normal range), so there is no immediate need to notify the doctor regarding bradycardia.
Correct Answer is D
Explanation
Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.
C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.
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