A 16-year-old patient sustained a head injury while playing soccer. When performing a neurologic check, the nurse looks at each pupil to determine

the state of consciousness.

if the shape is regular.

whether one pupil is larger than the other.

if they have become smaller.

Answer and Explanation

The Correct Answer is C

A.   While pupil response can be an indicator of consciousness, the primary concern when assessing pupils is to check for signs of increased intracranial pressure, such as unequal pupil size.
B.   The shape of the pupil is important to assess, but the concern here is typically more about the size and response to light, which can indicate a neurological issue.
C.   Unequal pupil sizes (anisocoria) can indicate neurological problems, such as increased intracranial pressure or brain injury, and requires further evaluation.
D.   Pupil size changes could indicate a variety of issues, but the focus should be on detecting unequal pupils, which can be a critical sign in head injury patients.

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Correct Answer is A

Explanation

A. The normal response to light in the eye is pupil constriction. This indicates that the optic and oculomotor nerves are functioning properly.
B. While a sluggish reaction can occur in some individuals, a noticeable sluggish response could indicate neurological issues, especially in a head injury.
C. Pupils should constrict in response to light, not dilate, unless there is a significant neurological impairment.
D. Pupil checks should ideally be performed in dim lighting for better visibility of pupillary reactions, not with the room lights on.

A. literacy assessment. B. financial history. C. cultural assessment. D. psychological history.

Correct Answer is C

Explanation

A. While literacy is an important consideration, the focus should be on understanding the patient's cultural background to ensure appropriate care and address any specific needs related to their ethnicity and traditions.
B. A financial history may be relevant but does not directly relate to the patient's immediate care needs regarding abdominal pain.
C. Cultural assessment is essential to understand the patient's values, beliefs, and preferences in healthcare, particularly in a diverse population, to ensure culturally competent care.
D. Psychological history could be useful in some cases, but it is secondary to cultural considerations in a patient with abdominal pain.

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A 16-year-old patient sustained a head injury while playing soccer. When performing a neurologic check, the nurse looks at each pupil to determine

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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