The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as:
a. Eye trauma. c. Severe brainstem damage.
b. Neurosurgical emergency. d. Indication of brain death.
ANS: B
The sudden appearance of a fixed and dilated pupil(s) is a neurosurgical emergency. The nurse should immediately report this finding. Although a dilated pupil may be associated with eye trauma, this child has experienced a neurologic insult. Pinpoint pupils or fixed, bilateral pupils for more than 5 minutes are indicative of brainstem damage. The unilateral fixed and dilated pupil is suggestive of damage on the same side of the brain. One fixed and dilated pupil is not suggestive of brain death.
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a. The supine position commonly used in the United States increases blood flow. b. The "all fours" position, on her hands and knees, is hard on her back. c. Frequent changes in position will help relieve her fatigue and increase her com-fort. d. In a sitting or squatting position her abdominal muscles will have to work harder.
The term that refers to legal definition and customary practice of a particular profession is
a. Precedent b. Scope of practice c. Sovereign immunity d. Self-regulation