A nurse is assessing a client in the emergency department when it is noted the left pupil is enlarged and fixed while the right pupil constricts to 2mm when exposed to light. Which of the following is a possible cause of unequal pupil sizing?

Normal variation in pupil size

Age-related changes

Ocular trauma

Excessive light exposure

Answer and Explanation

The Correct Answer is C

A.   There can be slight variations in pupil size but the difference described (one pupil enlarged and fixed, the other constricted and reactive to light) is not considered normal.

B.   Age-related changes in pupil size typically involve a gradual decrease in pupil size, not a sudden and dramatic difference between the two eyes.
C.   Unequal pupil size, especially when one pupil is fixed and dilated, is a classic sign of increased intracranial pressure (ICP), often caused by head trauma.
D.   Exposure to light would cause both pupils to constrict, not one to dilate and fix.

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Correct Answer is C

Explanation

A. A slight increase in temperature is common after surgery and might not necessarily indicate shock.
B. A slight decrease in respiratory rate is not indicative of shock. In fact, as shock progresses, respiratory rate often increases.
C. An increased heart rate is a classic compensatory mechanism in response to decreased blood volume, as the body tries to maintain blood pressure.
D. While a decrease in urinary output can be a sign of impending shock, it's often a later sign. In the early stages, the body prioritizes blood flow to vital organs, and urine output may still be within normal limits.

A. To convert atrial fibrillation to sinus rhythm B. To dissolve clots in the bloodstream C. To slow the response of the ventricles to the fast atrial impulses D. To reduce the risk of stroke in clients who have atrial fibrillation

Correct Answer is D

Explanation

A. To convert atrial fibrillation to sinus rhythm is the function of anti-arrhythmic medications, not anticoagulants like dabigatran.
B. This is the role of thrombolytic medications, not anticoagulants.
C. This is the function of beta-blockers or calcium channel blockers.
D. Dabigatran is an anticoagulant primarily used to prevent stroke in patients with atrial fibrillation by preventing blood clot formation.

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A nurse is assessing a client in the emergency department when it is noted the left pupil is enlarged and fixed while the right pupil constricts to 2mm when exposed to light. Which of the following is a possible cause of unequal pupil sizing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Correct Answer is C

Explanation

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following?

Correct Answer is D

Explanation

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