Explain the physiological mechanism for dilated (size 5), non-reactive pupils
What will be an ideal response?
Suggested response: Abnormal pupillary light reflex response or abnormal pupil size is often associated with an increased ICP and neurological deterioration. The effects from central nervous system depressants such as sedation and muscle relaxants, parasympatholytic and anticholinergic drugs and sympathomimetic drugs must be taken into consideration. Pupillary changes are highly correlated with brainstem oxygenation, intracranial hypertension and perfusion/ischaemia issues. More than one neuroanatomical pathway is involved in the control of the pupil. The location of the efferent oculomotor nerve from the midbrain to the superior orbital fissure is particularly important for assessing the commencement of descending transtentorial herniation and brainstem compression.
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When assessing a patient's general appearance, the nurse should include which question?
a. Is the patient's muscle strength equal in both arms? b. Is ptosis or facial droop present? c. Does the patient appropriately respond to questions? d. Are the pupils equal in reaction and size?
The nurse cares for children of all ages with a wide variety of illnesses and injuries. General consent or informed consent is required for care. Which of the following is the most important legal consideration?
A) Determining if the child is emancipated B) Establishing if the parents are competent C) Knowing the laws in the state where the care is being given D) Contacting the parents prior to emergency care
A 52-year-old patient has had a laryngectomy in treatment of cancer. A nursing diagnosis for the patient with a laryngectomy would be social isolation related to impaired verbal communication related to removal of the larynx
The correct nursing intervention would be a. complete care quickly. b. provide a pad and pencil or magic slate available. c. refrain from conversations with the patient to reduce his stress level. d. offer books or jigsaw puzzles for entertainment.
Across the lifespan, a nurse knows that the female heart
A) Is normally smaller than the male heart B) Weighs more than a male heart C) Is normally larger than a male heart D) Normally beats slower than a male heart