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. "Inhalants are central nervous system (CNS) depressants similar to alcohol." Inhalants are CNS depressants, but this response might not indicate full understanding of the risks and addictive nature of inhalants.

B. "The 'high' that I am getting is from hallucinogenic properties in the inhalant." This is incorrect because inhalants are not primarily hallucinogens; they depress the CNS, leading to effects similar to alcohol intoxication.

C. "Inhalants are easy to come by and highly addictive." This statement indicates the client understands the accessibility and addictive potential of inhalants, which is a critical aspect of the education provided by the nurse.

D. "When inhaling solvents, I get an instant CNS stimulation that is euphoric." While inhalants may provide a euphoric sensation, they are primarily CNS depressants, not stimulants. This response indicates a misunderstanding of their effects.

A. client's anxiety level decreased B. client's pain level decreased C. assessment completed D. client understood the importance of the assessment

Correct Answer is B

Explanation

A. client's anxiety level decreased: While reducing anxiety is important, it is not the initial priority when a client is experiencing physical pain that is affecting their ability to engage in the assessment.

B. client's pain level decreased: The initial desired outcome is to address the client's immediate physical pain. Once the pain is managed, the client will likely be better able to participate in the assessment and respond to questions about their mental health.

C. assessment completed: Completing the assessment is important, but it should not be prioritized over managing the client's immediate physical pain, which is currently hindering their ability to participate.

D. client understood the importance of the assessment: The client’s understanding of the assessment’s importance is less critical than addressing their immediate physical discomfort, which is a more pressing concern in this scenario.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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