During the examination of an unconscious patient., the nurse notes that the patient's pupils are fixed and dilated. What is the clinical significance of the nurse's assessment?
A) It suggests onset of metabolic problems.
B) It indicates paralysis on the right side of the body.
C) It indicates paralysis of the cranial nerve X.
D) It indicates an injury at the midbrain level.
Ans: D
Feedback: Pupils that are fixed and dilated indicate injury at the midbrain level.
You might also like to view...
Which nursing theorist is best known for her emphasis on interacting systems, including nurse and patient in goal setting and goal attainment?
a. Watson b. Roy c. King d. Orem
What is the priority nursing intervention when caring for a client with severe acute respiratory syndrome (SARS)?
a. Maintaining Standard Precautions b. Administering antibiotics c. Assessing oxygenation d. Making sure the client stays hydrated
A 1- to 2-inch needle should be used for intramuscular injections
Indicate whether the statement is true or false
The nursing staff members have exhausted all possible interventions to avoid placing a patient in restraints. Which of the following orders for physical restraints is written correctly?
1. 2/3/09, 1815, apply soft wrist restraints for 24 hours to prevent the removal of IV line, Dr. X 2. 2/3/09, apply restraints for 24 hours due to failure of nonrestraint nursing interventions, Dr. X 3. 2/3/09, 1815, apply soft wrist restraints for 48 hours to prevent injury, Dr. X 4. 2/3/09, To prevent falls apply restraints as needed at night, Dr. X