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."

Answer and Explanation

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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Correct Answer is B

Explanation

A. Auscultating for bowel sounds once a shift is important but does not directly relate to the respiratory condition.
B. Auscultating lung sounds at the beginning of a shift is a priority to assess for any signs of respiratory compromise or complications.
C. Monitoring skin turgor every shift is important for hydration status but is less critical in comparison to lung sounds for a patient with respiratory problems.
D. Monitoring peripheral pulses once a shift is important but does not address the respiratory condition directly.

A. increase in temperature. B. decrease in pulse. C. decrease in blood pressure. D. decrease in respirations.

Correct Answer is C

Explanation

A. Temperature often decreases in cases of severe blood loss due to shock and hypothermia.
B. A decrease in pulse is unlikely in severe blood loss. The body compensates with an increased heart rate.
C. A decrease in blood pressure is expected in cases of significant blood loss, as the body struggles to maintain adequate circulation.
D. Respirations may increase in response to blood loss, not decrease, as the body attempts to increase oxygen intake.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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