The nurse, assessing a patient with a Glasgow Coma Score 4, finds the patient's pupils to be pinpoint and nonreactive to light. The nurse realizes that this assessment finding can be caused by damage to the pons or by
1. opioid drug overdose.
2. metabolic disorders.
3. compression to the oculomotor nerve.
4. recent administration of atropine sulfate.
1
Rationale: In addition to the pons, pinpoint pupils can be caused by overdoses of opioids. Further assessment is needed to diagnose the problem. Metabolic disorders cause small but reactive pupils; compression to the oculomotor nerve causes a unilateral fixed and dilated pupil; and recent administration of atropine sulfate leads to dilated pupils.
You might also like to view...
The nurse receives an order from the physician to obtain the client's signature on an informed consent that has been completed and placed on the chart
The nurse asks the client and family if they have any questions about the procedure, and they say "no." The client signs the consent, and the nurse signs on the witness line, knowing that the signature implies: A) the client and family fully understand what is to be done during the procedure. B) the client and family have been fully informed about the procedure. C) the family and client are fully informed of alternative options to the procedure, potential complications, what is to done, and who will perform the procedure. D) the nurse witnessed that it was signed by the client.
It is important the community health nurse agree to do no harm to clients in working to heal clients in the least painful and harmful way possible. Which ethical principle applies to the community health nurse?
A) Respect for person B) Veracity C) Beneficence D) Nonmaleficence
A patient develops a high fever and has a urinary tract infection. The patient has malaise and is confused. The patient is
A) Septic B) Anorexic C) Lethargic D) Apneic
The nurse teaches adolescents that which method of birth control is 100% effective?
What will be an ideal response?