The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.
Unequal pupils
Pupil reaction quick
Pinpoint pupils
Absence of pupillary response
Pupil reacts to light
Correct Answer : A,C,D
A. Unequal pupils: Unequal pupils (anisocoria) can indicate a potential neurological issue, such as intracranial pressure or brain injury, especially after trauma. It is a significant finding requiring further evaluation.
B. Pupil reaction quick: Quick pupil reaction is typically normal and indicates proper neurological function, not a concern.
C. Pinpoint pupils: Pinpoint pupils can indicate opioid overdose or certain types of brainstem injury and should be evaluated as a potential neurological concern.
D. Absence of pupillary response: Absence of pupillary response to light can be a serious neurological concern, indicating severe brain injury or significant neurological compromise.
E. Pupil reacts to light: A pupil that reacts to light is a normal finding and indicates proper neurological function.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Offer the client fluids with meals. Offering fluids with meals may decrease the client's appetite by creating a sense of fullness, which could further reduce calorie intake and not aid in weight gain.
B. Increase fiber in the client's diet. While fiber is important for digestive health, it may also contribute to a feeling of fullness and might not directly help in increasing body weight in clients with anorexia.
C. Encourage the client to eat less protein. Protein is essential for maintaining muscle mass and overall health, especially in clients with AIDS. Reducing protein intake would not be beneficial for weight gain or health maintenance.
D. Provide supplemental vitamins and supplemental nutrition. Offering supplemental nutrition and vitamins can help increase caloric intake and ensure that the client receives essential nutrients to support weight gain and overall health. This is the most appropriate action to help increase the client's body weight.
Correct Answer is B
Explanation
A. Diarrhea: Opiates typically cause constipation, not diarrhea. Diarrhea is not a common finding with opiate use.
B. Pinpoint-sized pupils: Opiates commonly cause miosis, or pinpoint pupils. This is a classic sign of opiate use and is important for assessment.
C. Weight gain: Opiate use is not typically associated with weight gain; in fact, it can sometimes lead to decreased appetite and weight loss.
D. Bulimia: Bulimia is an eating disorder characterized by binge eating and purging. It is not a typical effect of opiate use.
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