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 B
Explanation
Choice A reason: Offering a finger may elicit sucking, not rooting, which involves head-turning toward a stimulus. Stroking the cheek triggers the rooting reflex, so this is incorrect for testing the specific reflex.
Choice B reason: Stroking the infant’s cheek near the mouth elicits the rooting reflex, causing the newborn to turn toward the stimulus, seeking to nurse. This is the correct technique for testing this reflex.
Choice C reason: Jarring the crib tests the Moro reflex, not rooting, which is unrelated to startle responses. Cheek stroking is specific to rooting, so this incorrect for the reflex being assessed.
Choice D reason: Stroking the foot edge tests the Babinski reflex, not rooting, which involves oral seeking. The cheek is the correct area to stimulate, so this is incorrect for the rooting reflex.
Correct Answer is C
Explanation
Choice A reason: Statements from the victim are valuable but not required for reporting elder abuse. Mandatory reporters must act on reasonable suspicion, as victims may be unable or unwilling to report due to fear or incapacity, making this incorrect.
Choice B reason: Witness statements support abuse cases but are not mandatory for reporting. Nurses must report based on suspicion, as waiting for witness corroboration could delay protection, making this an incorrect requirement for notification.
Choice C reason: As a mandatory reporter, a nurse must notify authorities based on reasonable suspicion of abuse or neglect, as per legal standards. This ensures timely intervention to protect vulnerable elders, even without definitive proof, making this correct.
Choice D reason: Proof of abuse or neglect is not required for reporting, as mandatory reporters act on suspicion. Requiring proof could delay or prevent reporting, leaving elders at risk, making this an incorrect threshold for notification.
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