A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?
"When I shine a light into the patient's eyes, the pupils should constrict."
"It is normal for the pupils to react sluggishly to light."
"When I shine a light into the patient's eyes, the pupils should dilate
"Pupil checks should be performed with the room lights on."
The Correct Answer is A
A. The normal response to light in the eye is pupil constriction. This indicates that the optic and oculomotor nerves are functioning properly.
B. While a sluggish reaction can occur in some individuals, a noticeable sluggish response could indicate neurological issues, especially in a head injury.
C. Pupils should constrict in response to light, not dilate, unless there is a significant neurological impairment.
D. Pupil checks should ideally be performed in dim lighting for better visibility of pupillary reactions, not with the room lights on.
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Related Questions
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.
Correct Answer is D
Explanation
A. Dyspnea refers to difficulty breathing or shortness of breath, which is not a normal breathing pattern.
B. Bradypnea is an abnormally slow rate of breathing, which is not normal unless it is related to certain medical conditions or medications.
C. Tachypnea refers to rapid breathing, which is often seen with fever, anxiety, or respiratory distress.
D. Eupnea refers to normal, unlabored breathing, which is the expected, healthy pattern of respiration in a resting state.
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