During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 8 hours earlier, the nurse notices the following changes: both pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest?
Normal findings
Need to recheck findings
Increased intracranial pressure
Brainstem injury
The Correct Answer is C
Choice A reason: Normal pupil findings include equal size (2–5 mm) and brisk reaction to light bilaterally. A fully dilated, nonreactive right pupil with a reactive left pupil indicates a neurological abnormality, not a normal finding, as it suggests significant brain dysfunction.
Choice B reason: Rechecking findings is prudent, but the described pupil changes—unilateral dilation and nonreactivity—are classic signs of a serious condition. Delaying action by only rechecking could miss critical intervention timing, as these findings strongly indicate a neurological emergency.
Choice C reason: A unilaterally dilated, nonreactive pupil with a normal contralateral pupil suggests increased intracranial pressure, often from a hematoma or swelling compressing the oculomotor nerve (Cranial Nerve III). This causes pupil dilation and loss of light reflex, requiring urgent intervention.
Choice D reason: Brainstem injury typically causes bilateral pupil changes, such as fixed, pinpoint, or dilated pupils, due to damage to brainstem nuclei. The unilateral findings here are more indicative of focal pressure (e.g., hematoma) than diffuse brainstem injury, making this less likely.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Cranial Nerve VII (facial nerve) controls facial expression muscles. Asking the patient to smile tests the nerve’s motor function, specifically the zygomaticus muscles, which elevate the mouth corners, making this a correct assessment task for this nerve.
Choice B reason: Closing eyes tightly assesses Cranial Nerve VII’s motor function, specifically the orbicularis oculi muscle, which closes the eyelids. Weakness or asymmetry indicates potential facial nerve dysfunction, making this a correct task for evaluating this nerve.
Choice C reason: Shrugging shoulders tests Cranial Nerve XI (spinal accessory nerve), which innervates the trapezius and sternocleidomastoid muscles. This action is unrelated to Cranial Nerve VII’s facial motor functions, making it an incorrect choice for this assessment.
Choice D reason: Frowning assesses Cranial Nerve VII’s control over the corrugator supercilii and procerus muscles, which wrinkle the brow and depress the mouth. This task evaluates facial nerve function, making it a correct choice for the assessment.
Choice E reason: Smelling a flower tests Cranial Nerve I (olfactory nerve), responsible for smell sensation. This is unrelated to Cranial Nerve VII’s motor functions for facial expressions, making it an incorrect task for assessing this nerve.
Correct Answer is A
Explanation
Choice A reason: Costovertebral angle tenderness is a classic sign of pyelonephritis, indicating kidney infection or inflammation. Percussing this area elicits pain in renal conditions, making it the correct condition to assess for tenderness.
Choice B reason: Cholecystitis causes pain in the right upper quadrant, not the costovertebral angle. Kidney-related pyelonephritis is linked to this tenderness, so this is incorrect for the assessment focus.
Choice C reason: Gastric ulcers cause epigastric pain, not costovertebral tenderness, which is renal-specific. Pyelonephritis is the condition associated with this sign, so this is incorrect for the suspected condition.
Choice D reason: Pancreatitis presents with abdominal pain, not costovertebral angle tenderness, which indicates kidney issues. Pyelonephritis is the relevant condition, so this is incorrect for the assessment.
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