The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.

Unequal pupils

Pupil reaction quick

Pinpoint pupils

Absence of pupillary response

Pupil reacts to light

Answer and Explanation

Correct Answer : A,C,D

A. Unequal pupils: Unequal pupils (anisocoria) can indicate a potential neurological issue, such as intracranial pressure or brain injury, especially after trauma. It is a significant finding requiring further evaluation.

B. Pupil reaction quick: Quick pupil reaction is typically normal and indicates proper neurological function, not a concern.

C. Pinpoint pupils: Pinpoint pupils can indicate opioid overdose or certain types of brainstem injury and should be evaluated as a potential neurological concern.

D. Absence of pupillary response: Absence of pupillary response to light can be a serious neurological concern, indicating severe brain injury or significant neurological compromise.

E. Pupil reacts to light: A pupil that reacts to light is a normal finding and indicates proper neurological function.

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Correct Answer is C

Explanation

A. the client feels vulnerable to stigma: While stigma can prevent clients from reporting suicidal thoughts, this is not the primary reason for initiating a suicide risk assessment.

B. young adults tend to use manipulation: Assuming that young adults manipulate their symptoms is not a valid reason for initiating a suicide risk assessment. This response is inappropriate and can harm the therapeutic relationship.

C. this is a standard assessment: A suicide risk assessment is a standard part of care for clients with depression and thoughts of hopelessness, even if suicidal ideation is not explicitly reported. This ensures comprehensive evaluation and appropriate intervention.

D. the client lives with extended family: The living situation may influence the support system, but it is not the primary reason to initiate a suicide risk assessment.

A. Normal pessimism of the elderly. B. A cry for sympathy. C. Normal grieving. D. Evidence of high suicide potential.

Correct Answer is D

Explanation

A. Normal pessimism of the elderly: This statement downplays the seriousness of the client’s feelings. Although some elderly individuals may experience sadness, these statements suggest a deeper issue that should not be considered normal.

B. A cry for sympathy: This response dismisses the client's feelings as attention-seeking, which could lead to missing a serious issue, such as depression or suicidal ideation.

C. Normal grieving: While grief can lead to feelings of sadness, the statements indicate a broader sense of hopelessness and worthlessness, which goes beyond normal grieving.

D. Evidence of high suicide potential: The client’s statements suggest feelings of hopelessness and despair, which are red flags for suicide risk, especially in elderly clients. This requires immediate assessment and intervention.

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The nurse is assessing the client's pupils following a sports injury. Which of the following assessment findings indicates a neurologic concern? Select all that apply.

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Correct Answer is C

Explanation

A client, age 79 years, tells the home visiting nurse, "I've been feeling down for the last few days. I don't have much to live for. My family and friends are all dead. My money's running out, and my health is failing." The nurse should assess this as:

Correct Answer is D

Explanation

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