During the examination of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: 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?
Herniated brainstem
Increased intracranial pressure
Subdural hemorrhage
Cerebral edema
The Correct Answer is B
Choice A reason: Herniated brainstem causes bilateral pupil changes and severe neurological signs, not unilateral dilation. Unilateral pupil dilation suggests increased intracranial pressure, so this is incorrect for these findings.
Choice B reason: Unilateral pupil dilation and nonreactivity, as seen in the right pupil, indicate increased intracranial pressure, often from mass effect compressing the oculomotor nerve. This is critical, making it the correct finding.
Choice C reason: Subdural hemorrhage may cause pressure but isn’t specific to these pupil changes. Unilateral dilation points to increased intracranial pressure as the immediate concern, so this is less precise.
Choice D reason: Cerebral edema contributes to pressure but is a broader term. Unilateral pupil dilation specifically suggests increased intracranial pressure, a more immediate and precise diagnosis, so this is incorrect.
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Choice C reason: Tying Pap smears to sexual activity is outdated.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 C
Explanation
Choice A reason: Homan sign tests for deep vein thrombosis, not balance. Swaying with eyes closed indicates a positive Romberg sign, so this is incorrect for the documented finding.
Choice B reason: Lack of coordination is vague and not specific to the Romberg test, which assesses proprioception. Positive Romberg sign describes the sway, so this is incorrect for documentation.
Choice C reason: A positive Romberg sign is documented when a patient sways or loses balance with eyes closed, indicating proprioceptive or cerebellar issues. This is the correct term for the finding.
Choice D reason: Ataxia describes general movement, not the specific Romberg test outcome. Swaying in this context is a Romberg sign, so this is incorrect for the nurse’s documentation.
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