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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Maintaining accurate records of intake and output: While monitoring intake and output is important for assessing fluid balance and kidney function, it is not as immediate a concern as maintaining an airway in an unconscious client.
B. Maintaining a patent airway: This is the highest priority because an unconscious client is at high risk of airway obstruction due to the loss of protective reflexes. Ensuring that the airway remains open is critical to prevent respiratory distress or arrest.
C. Inserting a nasogastric (NG) tube as prescribed: Inserting an NG tube might be necessary for feeding or draining gastric contents, but it is secondary to the more urgent need of ensuring a clear airway.
D. Providing appropriate pain control: Pain control is important but should be considered after addressing more immediate threats to the client's safety, such as maintaining a patent airway.
Correct Answer is B
Explanation
A. The client can obtain and maintain employment. While obtaining and maintaining employment can be a positive outcome, it does not specifically address the control of aggressive behaviors which are the focus here.
B. The client is free from aggressive behaviors. Being free from aggressive behaviors directly reflects successful treatment of aggressive symptoms in schizophrenia. This outcome specifically addresses the primary concern.
C. The client utilizes relaxation techniques. Utilizing relaxation techniques can be part of managing symptoms but does not directly measure the control of aggressive behaviours.
D. The client maintains healthy relationships with others. Maintaining healthy relationships is a positive outcome, but it is a broader goal and does not directly indicate control of aggressive behaviours.
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