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: 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.
Correct Answer is B
Explanation
Choice A reason: Writing a series of numbers tests attention or working memory, not recent memory recall. Recalling words after a delay specifically assesses short-term memory, which is more relevant for a 70-year-old, so this is not the best method.
Choice B reason: Asking a patient to recall four words after 10 minutes directly tests recent memory, a key cognitive function in older adults. This method is standard in assessments like the Mini-Mental State Exam, making it the best choice for evaluating memory.
Choice C reason: Verifying information like a mother’s maiden name tests long-term memory, not recent recall. Recent memory involves retaining new information, so recalling words after a delay is more appropriate, making this incorrect.
Choice D reason: Naming past presidents relies on long-term memory and general knowledge, not recent memory. Recalling newly learned words after 10 minutes better assesses short-term memory, so this is not the best approach for recent memory.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.