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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
A. Bradycardia is defined as a heart rate lower than 60 beats per minute. Therefore, 62 beats per minute is not bradycardic.
B. 59 beats per minute would be considered bradycardic, as it is below 60.
C. 64 beats per minute is within normal limits.
D. 60 beats per minute is on the threshold of bradycardia but typically is still within normal limits for some individuals.
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