A nurse is assessing a client in the emergency department when it is noted the left pupil is enlarged and fixed while the right pupil constricts to 2mm when exposed to light. Which of the following is a possible cause of unequal pupil sizing?

Normal variation in pupil size

Age-related changes

Ocular trauma

Excessive light exposure

Answer and Explanation

The Correct Answer is C

A.   There can be slight variations in pupil size but the difference described (one pupil enlarged and fixed, the other constricted and reactive to light) is not considered normal.

B.   Age-related changes in pupil size typically involve a gradual decrease in pupil size, not a sudden and dramatic difference between the two eyes.
C.   Unequal pupil size, especially when one pupil is fixed and dilated, is a classic sign of increased intracranial pressure (ICP), often caused by head trauma.
D.   Exposure to light would cause both pupils to constrict, not one to dilate and fix.

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Correct Answer is B

Explanation

A. This would be overwhelming for a client with global aphasia, as they have difficulty processing information.
B. This is the correct approach. Breaking down information into smaller, manageable chunks makes it easier for the client to understand.
C. While consistency is important, limiting communication to one method can be restrictive. It's better to use a variety of techniques (verbal, nonverbal, written, etc.) to support understanding.
D. This can be limiting and frustrating for the client. It's essential to encourage all forms of communication, even if it's difficult.

A. Jerking contractions of the head and neck B. Pinpoint pupils C. Pronation of the arms D. Dorsiflexion of the great toe

Correct Answer is D

Explanation

A. Jerking contractions of the head and neck is more indicative of seizures or other neurological conditions.
B. Pinpoint pupils can be associated with various conditions, including opioid overdose or pontine hemorrhage, but it's not specifically related to Babinski's sign.
C. Pronation of the arms is a general assessment finding, not specifically indicative of a neurological issue.
D. Dorsiflexion of the great toe is the classic response for Babinski's sign. It is an abnormal reflex indicating upper motor neuron damage.

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A nurse is assessing a client in the emergency department when it is noted the left pupil is enlarged and fixed while the right pupil constricts to 2mm when exposed to light. Which of the following is a possible cause of unequal pupil sizing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has global aphasia. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assessing the reflexes of a client who has an unrepaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibits Babinski's sign?

Correct Answer is D

Explanation

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