The nurse is assessing the pupils of a client who has had a head injury. What does the nurse recognize as a parasympathetic effect?

Roth's spots.

One pupil is dilated and the opposite pupil is normal.

Dilated pupils.

Constricted pupils.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Roth's spots are retinal hemorrhages with pale centers, indicative of certain systemic conditions, but do not relate to pupil response or parasympathetic effects.

Choice B rationale

One pupil being dilated while the other is normal could indicate a variety of issues, but not specifically a parasympathetic effect. This condition is known as anisocoria.

Choice C rationale

Dilated pupils, or mydriasis, are usually the result of sympathetic stimulation, not a parasympathetic effect, which involves constriction of the pupils.

Choice D rationale

Constricted pupils, or miosis, are a parasympathetic effect typically resulting from increased activity of the parasympathetic nervous system, which reduces pupil size.

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Correct Answer is D

Explanation

Choice A rationale

Necrosis is tissue death resulting from prolonged pressure, often a consequence rather than the direct cause of pressure ulcers. The primary cause is sustained pressure impairing blood flow.

Choice B rationale

Low capillary pressure does not directly cause pressure ulcers. They result from sustained external pressure exceeding capillary perfusion pressure, leading to ischemia and tissue damage.

Choice C rationale

Increased mobility actually prevents pressure ulcers by reducing sustained pressure on any one area, enhancing blood flow and tissue health. Immobility is a significant risk factor, not increased mobility.

Choice D rationale

Extrinsic factors like sustained pressure, friction, shear, and moisture contribute directly to pressure ulcer development by compromising skin integrity and blood flow, leading to tissue ischemia and damage.

A. Pustule. B. Macule. C. Vesicle. D. Cyst. E. Cyst.

Correct Answer is C

Explanation

Choice A rationale

A pustule is an elevated, round lesion filled with pus, not serum. Pustules are commonly seen in acne or infections.

Choice B rationale

A macule is a flat, discolored area of the skin that is not elevated. Macules do not contain fluid and are often seen in conditions like freckles or flat moles.

Choice C rationale

A vesicle is an elevated, round lesion filled with clear serum. Vesicles can result from conditions such as chickenpox, herpes simplex, or dermatitis.

Choice D rationale

A cyst is an elevated, round lesion filled with semi-solid material or fluid. Cysts are typically deeper in the skin compared to vesicles.

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The nurse is assessing the pupils of a client who has had a head injury. What does the nurse recognize as a parasympathetic effect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Pressure ulcers are caused by:

Correct Answer is D

Explanation

During the skin assessment of a client, the nurse observes a skin lesion that is elevated, round, and filled with serum. Identify the type of lesion.

Correct Answer is C

Explanation

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