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

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A reason: The submandibular glands are palpable below the mandible, but occipital glands do not exist as salivary glands. The occipital region relates to lymph nodes or muscles, not salivary structures, making this an incorrect pair for palpation.

Choice B reason: The parotid glands are palpable near the ears, but jugulodigastric refers to lymph nodes, not salivary glands. This misidentification of anatomical structures makes this pair incorrect for assessing salivary gland palpation.

Choice C reason: Occipital and submental regions do not contain salivary glands. Submental lymph nodes exist, but neither these nor occipital structures are salivary glands, making this pair anatomically incorrect for the nurse’s palpation assessment.

Choice D reason: The parotid glands, located anterior to the ears, and submandibular glands, below the mandible, are the two pairs of salivary glands accessible for palpation. Their anatomical positions allow external assessment, making this the correct choice.

A. White with prominent capillaries B. Pearly gray and transparent C. Pulled in at the base of the cone of light D. Light pink with a slight bulge

Correct Answer is B

Explanation

Choice A reason: A normal tympanic membrane is not white with prominent capillaries. Such an appearance may indicate inflammation or infection (e.g., otitis media), where increased vascularity or opacity occurs, making this an abnormal and incorrect characteristic.

Choice B reason: A normal tympanic membrane is pearly gray, slightly translucent, with a visible cone of light reflecting off its taut surface. This reflects healthy middle ear anatomy, with no fluid or inflammation, making this the correct description.

Choice C reason: A pulled-in tympanic membrane suggests negative middle ear pressure, often due to eustachian tube dysfunction, not a normal finding. The normal membrane is flat or slightly concave, making this an incorrect characteristic.

Choice D reason: Light pink with a slight bulge suggests inflammation or fluid (e.g., otitis media), not a normal tympanic membrane. Normal membranes are pearly gray and flat, not pink or bulging, making this an incorrect description.

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Naxlex Comprehensive Predictor Exams

When examining the face, the nurse is aware that which two pairs of salivary glands are accessible for palpation?

Correct Answer is D

Explanation

A nurse examines a patient’s tympanic membranes with an otoscope. The nurse understands the normal tympanic membrane exhibits which normal characteristic?

Correct Answer is B

Explanation

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The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. How should the nurse document this finding?

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