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 A

Explanation

A. Atrial fibrillation is consistent with the symptoms described. It causes irregular palpitations and dizziness due to the rapid and irregular ventricular rate. The significant pulse deficit can occur because the irregular rhythm may lead to intermittent weak or absent pulses. The ECG typically shows an irregular rhythm with no identifiable P waves and an irregularly irregular ventricular response.
B. Sinus bradycardia does not usually cause a rapid and irregular heart rate. It is characterized by a regular rhythm with a slow heart rate. While it can cause fatigue and dizziness, it does not typically present with an irregular rhythm or a significant pulse deficit. Therefore, it is less consistent with the symptoms described.
C. Sinus tachycardia is characterized by a rapid but regular heart rate. It does not typically present with an irregular rhythm or significant pulse deficit. While it may cause symptoms such as palpitations and

dizziness, the regular rhythm and absence of irregularity in the ECG make it less likely to be the cause of the significant irregular pulse deficit described.
D. First-degree AV block does not usually cause a rapid and irregular heart rate. It typically presents with a regular rhythm but with a prolonged PR interval. It is not typically associated with irregular palpitations or a significant pulse deficit. The symptoms described are not characteristic of first-degree AV block.

A. "DIC is controllable with lifelong heparin usage." B. "DIC is characterized by an elevated platelet count." C. "DIC is a genetic disorder involving a vitamin K deficiency." D. "DIC is caused by abnormal coagulation involving fibrinogen."

Correct Answer is D

Explanation

A. Heparin can be used to manage DIC but it's not a lifelong treatment and is part of a complex management plan.
B. DIC actually leads to a decreased platelet count due to excessive clotting.
C. DIC is an acquired condition, not a genetic one, and while vitamin K is involved in clotting, it's not the primary cause of DIC.
D. DIC is a complex disorder involving uncontrolled clotting and bleeding due to the depletion of clotting factors, including fibrinogen.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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