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 C
Explanation
A. Comprehend spoken words: This is part of global aphasia, but it does not fully encompass the deficits associated with this condition. Global aphasia involves more extensive language impairment.
B. Form words that are understandable: This is part of global aphasia, but it alone does not fully capture the severity of the language deficit, as it also includes comprehension issues.
C. Form words that are understandable or comprehend spoken words: Global aphasia is the most severe form of aphasia, characterized by profound impairment in both the ability to produce understandable speech and comprehend spoken language. This choice accurately reflects the full scope of the language deficits in global aphasia.
D. Speak at all: Clients with global aphasia may still attempt to speak, but their speech is typically not understandable and is often meaningless. Therefore, saying they cannot "speak at all" is not entirely accurate.
Correct Answer is B
Explanation
A. "I feel like everyone depends on me too much." This statement indicates a sense of responsibility and connection to others, which may not directly indicate suicidal ideation.
B. "Life has lost its meaning for me." This statement is a strong indicator of hopelessness, which is a key risk factor for suicide. The client feels that life is meaningless, which could indicate a desire to end their life.
C. "I wish I could just take a vacation and get away from it all." While this statement may indicate stress or a desire to escape, it does not directly suggest suicidal intent.
D. "I feel like a failure and wish one thing would just go right." This statement indicates frustration and low self-worth, but it doesn't necessarily indicate an immediate risk of suicide as clearly as statement B.
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