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

Answer and Explanation

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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Correct Answer is A

Explanation

A. Tolerance: Tolerance occurs when an individual requires increasing amounts of a substance to achieve the same effect. This can explain why a person with a high blood alcohol level might not appear intoxicated if they have developed tolerance.

B. Addiction: Addiction is a chronic disease involving compulsive substance use. While related to tolerance, addiction itself does not specifically explain the lack of observable intoxication symptoms.

C. Alcoholism: Alcoholism is a condition involving dependency on alcohol. It can involve tolerance, but the term "alcoholism" does not specifically address the immediate observation of high alcohol levels without visible intoxication.

D. Relapse: Relapse refers to returning to substance use after a period of abstinence. It does not specifically explain the lack of visible intoxication despite high blood alcohol levels.

A. Most restrictive B. Least restrictive C. Nursing home D. Transitional care unit

Correct Answer is D

Explanation

A. Most restrictive: A most restrictive environment may not be necessary if the client does not require intensive supervision or care.

B. Least restrictive: A least restrictive environment is generally preferred if the client can function with less supervision and support. It supports independence while providing necessary care.

C. Nursing home: A nursing home may be appropriate for clients needing extensive care, but it is often more restrictive than needed for clients who do not require 24-hour nursing care.

D. Transitional care unit: A transitional care unit is designed to support clients transitioning from hospital to home or other settings, which may be suitable if the client needs further rehabilitation or adjustment.

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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.

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