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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Elevating the head of the bed is a cornerstone of managing increased intracranial pressure (ICP). Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, helping to reduce ICP.
B. A brightly lit environment can stimulate the patient and increase ICP. A calm, dark environment is preferred.
C. Fluid restriction, not encouragement, is often necessary to manage ICP. Excessive fluid can increase intracranial volume.
D. Controlled coughing and deep breathing are important for lung expansion but coughing and straining can increase ICP. Gentle breathing exercises are preferred.

A. Elective cardioversion B. CPR C. Radiofrequency catheter ablation D. Defibrillation

Correct Answer is A

Explanation

A. Elective cardioversion is a procedure used to restore a normal heart rhythm by delivering a controlled electrical shock to the heart. It is generally used for patients with stable atrial or ventricular arrhythmias who do not respond to medication. In the case of stable VT, elective cardioversion might be considered if the arrhythmia is causing symptoms or if the patient’s condition changes
B. CPR is an emergency procedure used when a person’s heart has stopped beating (cardiac arrest) or when they are not breathing. It is not indicated for a stable VT because the patient is still stable and conscious, and CPR is not used for arrhythmias like VT in a stable patient.
C. Radiofrequency catheter ablation is a procedure used to destroy abnormal electrical pathways in the heart that cause arrhythmias. This is often used as a treatment for recurrent or persistent VT, especially if medication or cardioversion fails to manage the condition effectively. For a stable patient with VT, this treatment might be considered in the long-term management plan rather than as an immediate intervention.
D. Defibrillation is the use of an electrical shock to the heart to restore a normal rhythm in cases of life- threatening arrhythmias such as ventricular fibrillation or pulseless VT. It is not used for stable VT because the patient still has a pulse and is not in immediate danger of cardiac arrest

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 has increased intracranial pressure. Which of the following interventions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who reports heart palpitations that come and go. An ECG confirms the client is experiencing episodes of ventricular tachycardia (VT). The client is stable. The nurse should anticipate the need for taking which of the following actions?

Correct Answer is A

Explanation

A nurse is doing rounds and notes a patient in the following position: How would the nurse document this finding?

A nurse is caring for a 73-year-old client in the emergency department (ED). Exhibits It has been identified that the client is in sepsis. Select the 4 actions that the nurse should complete in the first hour to manage sepsis and prevent further complications?

A nurse is preparing to administer meperidine 35 mg IM to a client every 6 hr PRN for pain. Available is meperidine injection 75 mg/mL. How m mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

Exhibits A nurse is caring for a client who has a seizure disorder. (Select all that apply.)

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?

A nurse is assessing a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply)

Exhibits A nurse is providing discharge teaching. Which of the following client statements indicate an understanding of the teaching? Client Statements

A nurse is caring for a client who has atrial fibrillation and receives digoxin daily. Before administering this medication, which of the following actions should the nurse take?