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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pulse oximetry works by using light absorption to measure the oxygen saturation of hemoglobin in the blood, which typically occurs through the capillary bed in areas like the finger or earlobe.
B. The pulse oximeter does not measure the amount of blood passing through the sensor directly, but rather the oxygen content of the blood.
C. The pulse oximeter does not assess the warmth of the skin as a mechanism for measuring oxygenation.
D. Pulse oximeters measure oxygen saturation levels, not the respiratory rate or blood pressure.
Correct Answer is C
Explanation
A. The brachial artery should be at heart level, not waist level, to ensure accurate blood pressure readings.
B. While chatting with the patient may help reduce anxiety, it is not directly related to positioning for accurate blood pressure measurement.
C. Having the patient place their feet flat on the floor ensures proper positioning and helps prevent any interference with blood pressure readings.
D. The arm should be at heart level, not at the shoulder, for accurate readings.
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