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 C
Explanation
A. While extremity inspection is important, it is not as directly related to assessing back pain as evaluating the back itself.
B. Auscultating the lungs is essential in respiratory assessments but is not the priority when examining a patient with back pain.
C. Percussion of the flank areas is a key part of the physical examination for back pain, particularly if there are concerns of kidney involvement or other internal issues causing discomfort.
D. Bowel sounds are not directly related to back pain unless gastrointestinal issues are suspected.
Correct Answer is D
Explanation
A. Rinsing the thermometer with water is not necessary to ensure an accurate reading. The thermometer should be cleaned after use but rinsing with water does not directly ensure accuracy.
B. Using a dry cotton ball to dry the thermometer is unnecessary and could leave fibers on the device that may interfere with reading accuracy.
C. Wiping the thermometer with alcohol helps sanitize it but does not directly influence the accuracy of the reading.
D. Shaking down the galinstan alloy to below normal is necessary to reset the thermometer before use, ensuring that the mercury level is accurate when taking a new temperature.
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