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. "Do you go by he, she, or they?" This question is direct and acknowledges the importance of pronouns, but it might be better phrased to be more open-ended and respectful.
B. "What pronouns do you go by?" This is the most respectful and open-ended approach, allowing the client to express their preferred pronouns without making assumptions. It demonstrates a clear understanding of the importance of gender identity and respects the client's autonomy.
C. "What led to this hospital admission?" While this question is relevant to the client’s care, it does not address the client's gender identity directly, which is crucial in this context.
D. "What brings you in today?" Similar to option C, this question focuses on the reason for the hospital visit but does not address the client's gender identity, missing an opportunity to show respect for their identity.
Correct Answer is D
Explanation
A. Instruct to resume regular activities such as driving. It is not safe to instruct the client to resume activities like driving immediately, especially at the beginning of lithium therapy, as lithium can cause side effects that may impair the client's ability to safely perform tasks such as driving.
B. Administer lithium before meals. Lithium is typically taken with food to minimize gastrointestinal upset. Administering it before meals may increase the risk of side effects like nausea.
C. Withhold if serum level is less than 1.5 mEq. Lithium should be withheld if the serum level is above the therapeutic range (typically 0.6–1.2 mEq/L), as higher levels can lead to toxicity. Withholding lithium if the level is less than 1.5 mEq/L is incorrect and could lead to inadequate treatment.
D. Instruct to avoid breastfeeding. Lithium is excreted in breast milk and can pose a risk to the infant, so the client should be advised against breastfeeding while on lithium therapy.
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