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

Answer and Explanation

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.

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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.

A. Let’s check with the physician to see if you are a candidate for this vaccine B. This vaccine is only for girls who have not yet started to become sexually active C. The vaccine cannot protect you now that you already have an HPV infection D. The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that today

Correct Answer is C

Explanation

Choice A reason: Checking with the physician delays addressing the patient’s misunderstanding. The HPV vaccine does not treat existing infections or warts, as it is preventive, making this response less direct and informative than needed.

Choice B reason: The HPV vaccine is not limited to those not yet sexually active; it is recommended up to age 26, even for those with sexual history. This statement is outdated and incorrect, as vaccination can still benefit some with prior exposure.

Choice C reason: The HPV vaccine prevents new HPV infections but does not treat existing infections or genital warts, which are caused by specific HPV strains. Since the patient already has warts, the vaccine won’t help, making this the correct response.

Choice D reason: While the HPV vaccine is approved for ages 9–26, it does not treat existing infections or warts. Starting it without clarifying its preventive role misleads the patient, making this an incorrect and misleading response.

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Naxlex Comprehensive Predictor Exams

What is the best time for the nurse to measure a patient's respirations?

Correct Answer is D

Explanation

During a health history, a 22-year-old woman asks, “Can I get that vaccine for human papilloma virus (HPV)? I have genital warts and I’d like them to go away!” What is the nurse’s best response?

Correct Answer is C

Explanation

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