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 C

Explanation

A. Temperature often decreases in cases of severe blood loss due to shock and hypothermia.
B. A decrease in pulse is unlikely in severe blood loss. The body compensates with an increased heart rate.
C. A decrease in blood pressure is expected in cases of significant blood loss, as the body struggles to maintain adequate circulation.
D. Respirations may increase in response to blood loss, not decrease, as the body attempts to increase oxygen intake.

A. bell of the stethoscope on top of the patient's gown. B. diaphragm of the stethoscope directly on the patient's skin. C. diaphragm of the stethoscope on top of the patient's gown. D. bell of the stethoscope directly on the patient's skin.

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.

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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

When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

Correct Answer is C

Explanation

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 assesses that the 86-year-old patient is experiencing orthostatic hypotension when assessments indicate: (Select all that apply.)

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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

Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

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