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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["5.3"]
Explanation
1 pound = 0.453592 kilograms
28 pounds = 28 * 0.453592 = 12.7 kilograms
Dose = weight in kg * prescribed dose Dose = 12.7 kg * 10 mg/kg = 127 mg
The medication is availableas 120 mg/5 mL. To find the volume for 127 mg:
Volume = (desired dose / concentration) * volume Volume = (127 mg / 120 mg) * 5 mL
Volume ≈ 5.29 mL
Therefore, the nurse should administer approximately 5.3 mL of acetaminophen.
Correct Answer is B
Explanation
A. Cryoprecipitates are primarily used to treat bleeding disorders and conditions such as hemophilia or fibrinogen deficiencies. They are not the first-line treatment for hypovolemic shock, which is generally due to significant blood or fluid loss rather than clotting deficiencies.
B. Packed RBCs are a critical component in the management of hypovolemic shock, especially when the shock is due to significant blood loss. Administering packed RBCs helps restore the blood volume and improve oxygen delivery to tissues. This is particularly important in cases where the patient has lost a large volume of blood due to trauma, surgery, or other causes.
C. Albumin is used to treat hypovolemic shock when there is a need to increase intravascular volume due to fluid loss that results in low oncotic pressure. It is particularly useful in cases of burns, liver disease, or other conditions where fluid leaks into the interstitial space. While it can be used to manage hypovolemic shock, packed RBCs are typically the primary choice for blood loss.
D. Platelets are used to treat bleeding disorders where there is a deficiency in platelet count or function, such as in thrombocytopenia or during chemotherapy. They are not typically used for hypovolemic shock unless the shock is complicated by severe bleeding and platelet dysfunction.
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