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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. The bell is used to detect low-pitched sounds, but abnormal heart sounds are often high-pitched, requiring the diaphragm.
B. The diaphragm of the stethoscope is best for detecting high-pitched heart sounds, such as murmurs or abnormal rhythms.
C. The diaphragm on top of the gown would create interference and prevent proper auscultation of heart sounds.
D. The bell is used for lower-pitched sounds and is not the best choice for auscultating abnormal heart sounds.

A. measuring the oxygenated hemoglobin through a capillary bed. B. assessing the amount of blood passing through the sensor. C. assessing the relative warmth of the skin on the monitored part. D. measuring the respirations to the blood pressure via infrared rays.

Correct Answer is A

Explanation

A. Pulse oximetry works by using light absorption to measure the oxygen saturation of hemoglobin in the blood, which typically occurs through the capillary bed in areas like the finger or earlobe.
B. The pulse oximeter does not measure the amount of blood passing through the sensor directly, but rather the oxygen content of the blood.
C. The pulse oximeter does not assess the warmth of the skin as a mechanism for measuring oxygenation.
D. Pulse oximeters measure oxygen saturation levels, not the respiratory rate or blood pressure.

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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

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Naxlex Comprehensive Predictor Exams

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

Correct Answer is B

Explanation

The nurse explains to a patient that the pulse oximeter can measure the arterial oxygen by:

Correct Answer is A

Explanation

The nurse notes that a patient has an exaggerated lumbar curve. This is indicative of

The nurse covers a newborn baby's head with a cap. because the head:

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