When assessing an adult after a fall, the nurse notes a dilated ...

[EY67]

When assessing an adult after a fall, the nurse notes a dilated pupil on the right and a hematoma in the right temporal area. The nurse realizes that this likely means that
 
  1. the process affecting the pupil is occurring locally on the right side (ipsilateral pupil dilation).
  2. the process affecting the pupil is occurring on the opposite side and is unrelated to the right temporal hematoma.
  3. the process affecting the right pupil is temporary and soon both pupils will be equal in size.
  4. the process causing the right pupil to dilate is a result of a metabolic process.

Question 2

Decerebrate posturing is present in an unconscious patient following a motor vehicle accident. The nurse expects to see which position in this patient?
 
  accident. The nurse expects to see which position in this patient?
  1. The arms and legs are hyperextended and arms are hyperpronated.
  2. The arms are folded over the chest and spasms are rhythmic.
  3. The arms are pulled inward and the head is turned to the side.
  4. The arms and legs have tonicclonic seizure activity.

[maya.nigrin17@yahoo.com]

Answer to Question 1

Correct Answer: 1
Generally, when a process is occurring locally, the pupil on the same side (ipsilateral) is affected. If the process affecting the pupil were on the opposite side, the left pupil would be dilated. There is not enough information to determine whether the condition is temporary or caused by a metabolic process.

Answer to Question 2

Correct Answer: 1
Decerebrate posture is displayed by hyperextension of the arms and legs and hyperpronation of the arms. Decerebration is considered a sign that the patient has a serious injury with a poor prognosis. The other options do not accurately describe decerebrate posture. Tonicclonic movements are associated with seizures.

[EY67]

Excellent

[Dnite]

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