A nurse is instructing a nursing student on performing pupillary checks on a patient with a possible head injury. Which statement indicates that the nursing student understands the concept?
"When I shine a light into the patient's eyes, the pupils should constrict."
"It is normal for the pupils to react sluggishly to light."
"When I shine a light into the patient's eyes, the pupils should dilate
"Pupil checks should be performed with the room lights on."
The Correct Answer is A
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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Temperature monitoring is important but not a top priority when a patient is receiving opiates unless there is suspicion of infection.
B. Pulse monitoring is also important but does not immediately indicate issues with opiate use.
C. Blood pressure is influenced by opiate use, but the primary concern is respiratory function due to the risk of respiratory depression.
D. Respirations should be closely monitored because opiates can significantly depress the respiratory system, leading to hypoventilation or respiratory arrest, which is the most critical risk.
Correct Answer is A
Explanation
A. This is because the patient's blood pressure of 98/66 mm Hg, while on the lower side, may be normal for them. It's important to compare it to their baseline to determine if there has been a significant change.
B. The blood pressure is within a normal range for an adult, so immediate notification of hypotension is not required.
C. This can be done after determining if there is a significant change from the baseline.
D. The pulse is not bradycardic (it is within a normal range), so there is no immediate need to notify the doctor regarding bradycardia.
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