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 D
Explanation
Choice A reason: Frequency refers to frequent urination, not difficulty starting the stream. Hesitancy describes the specific symptom of delayed urine flow, often in prostate issues, so this is incorrect for documentation.
Choice B reason: Urgency is the sudden need to urinate, not trouble initiating the stream. Hesitancy captures the patient patient’s symptom of starting urination, making this incorrect for the term used.
Choice C reason: Spray is not a medical term for urinary symptoms; it’s irrelevant to starting difficulty. Hesitancy is the precise term for this issue, so this is incorrect for documentation purposes.
Choice D reason: Hesitancy is the term used for difficulty initiating the urine stream, often due to obstruction like benign prostatic hyperplasia. This matches the patient’s symptom, making it the correct term for documentation.
Correct Answer is D
Explanation
Choice A reason: Measuring respirations during pulse assessment can lead to inaccurate counts, as patients may alter their breathing when aware of pulse measurement. Conscious awareness often causes irregular or controlled breathing, which does not reflect the true respiratory rate, making this an unreliable time.
Choice B reason: Auscultation involves listening to lung or heart sounds, which requires patient cooperation and often affects breathing patterns. Patients may consciously modify their respirations during this process, leading to inaccurate respiratory rate measurements, rendering this an unsuitable time for assessment.
Choice C reason: Interviewing involves patient interaction, which can influence breathing due to speech or emotional responses. This conscious activity often results in irregular or controlled breathing patterns, making it an unreliable time to accurately measure the patient’s natural respiratory rate.
Choice D reason: Measuring respirations when the patient is sleeping ensures an undisturbed, natural breathing pattern, as the patient is unaware of the assessment. This allows the nurse to count the respiratory rate accurately, reflecting the true resting state, making it the optimal time.
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