High everything vs low everything
Before you read
Test yourself first: 3 questions
Question 1 of 3
A nurse checks pupillary response in a client with a head injury. The right pupil is fixed and dilated while the left reacts normally. What does this finding most likely indicate?
Answer: B. A unilateral fixed and dilated pupil suggests compression of the oculomotor nerve (CN III) on that side, often from an expanding mass or herniation, and warrants immediate notification of the provider.
Question 2 of 3
A client with acute coronary syndrome is having chest pain and receives sublingual nitroglycerin. After the first tablet, the pain persists. What is the nurse's appropriate action?
Answer: B. For ongoing chest pain, the standard teaching is to give one sublingual nitroglycerin tablet every 5 minutes for up to 3 doses, checking blood pressure between doses because nitroglycerin causes vasodilation and hypotension. If pain is unrelieved, emergency care or provider notification is needed. Giving all three at once, waiting 30 minutes, or doubling the dose are unsafe.
Question 3 of 3
A client diagnosed with a lumbar herniated disc reports radiating pain down the posterior leg. Which finding is consistent with sciatic nerve (L5-S1) involvement?
Answer: A. A herniated lumbar disc compressing the nerve root produces radicular pain, numbness, or tingling radiating along the dermatome down the buttock and posterior leg, often with a positive straight-leg raise test and possible weakness. Pain confined to the upper arm reflects cervical, not lumbar, pathology.
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References
Clinical references for this topic
