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
Explanation
Choice A reason: Guidelines recommend the first Pap smear at age 21, regardless of sexual activity, to screen for cervical cancer. This age balances the risk of detecting clinically significant abnormalities while avoiding unnecessary testing in younger women, whose HPV infections often resolve.
Choice B reason: Age 16 is too early for routine Pap smears, as cervical cancer is rare in adolescents, and HPV infections often clear spontaneously. Screening at this age may lead to overdiagnosis and unnecessary procedures, making it an incorrect recommendation.
Choice C reason: Tying Pap smears to sexual activity is outdated. Current guidelines recommend starting at age 21, as earlier screening in sexually active younger women often detects transient HPV infections, leading to overtreatment, making this an incorrect criterion.
Choice D reason: Age 18 is not the recommended starting point for Pap smears, as cervical cancer risk is low in this age group, and screening may lead to unnecessary interventions. Guidelines specify age 21 for routine screening, making this choice incorrect.
Correct Answer is B
Explanation
Choice A reason: Reading handheld print tests reading near vision, not standard visual acuity, which requires distance assessment. The Snellen chart at 20 feet is the standard, so this is incorrect for acuity testing.
Choice B reason: The Snellen chart, positioned 20 feet away, is the standard method for assessing visual acuity in adolescents, providing a reliable measure of distance vision. This is the correct procedure for the nurse.
Choice C reason: The confrontation test assesses peripheral vision, not central acuity. The Snellen chart measures sharpness of vision, so this is incorrect for the purpose of visual acuity assessment.
Choice D reason: Reading newsprint at 12–14 inches tests near vision, not distance acuity, which is the standard for screening. The Snellen chart at 20 feet is appropriate, so this is incorrect.
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