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 patient should stand 20 feet away from the Snellen chart to accurately measure visual acuity, which is the standard procedure.

B. The number beside the largest print is not the correct visual acuity score; the patient must read progressively smaller lines.
C. Testing with reading glasses is appropriate only for patients who need them for close-up vision, but the Snellen test typically measures distance vision.
D. The distance should be 20 feet, not 50 feet, to ensure proper testing conditions.

A. respirations gradually decreasing in rate and depth. B. rapid wheezing respirations for two or three breaths with short periods of apnea. C. a breathing pattern of dyspnea followed by a short period of apnea. D. quick shallow respirations with long periods of apnea.

Correct Answer is C

Explanation

A. Gradual decreases in rate and depth are typically seen in other respiratory conditions, not Cheyne- Stokes breathing.
B. Wheezing is not associated with Cheyne-Stokes breathing but may be related to airway obstructions or lung conditions.
C. Cheyne-Stokes breathing is characterized by a pattern of deep, rapid breathing followed by a period of apnea, commonly seen in terminally ill patients.
D. Quick shallow respirations with long periods of apnea are not characteristic of Cheyne-Stokes breathing.

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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

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Naxlex Comprehensive Predictor Exams

The nurse tells a patient that he will be performing a visual acuity test using the Snellen eye chart. The patient asks how the test is done. The nurse's best reply is:

Correct Answer is A

Explanation

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding:

Correct Answer is C

Explanation

It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:

A type of Korotkoff sound that indicates the diastolic pressure in children and in some adults is

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:

To correctly determine the strength of a patient's lower extremities during a neurological examination, the nurse asks the patient to:

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a:

When performing an initial assessment on a patient, which piece of information is of highest priority?