During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest?

Correct Answer: B

Rationale: The correct answer is B: Increased intracranial pressure. The sudden change in pupil size and reactivity indicates a neurological emergency, likely due to increased pressure within the skull. The dilated and nonreactive pupil on the right side (anisocoria) is a sign of uncal herniation, a life-threatening condition where brain structures shift and compress the third cranial nerve. The left pupil's normal size and reaction indicate that it is still functioning properly. This asymmetrical pupil response is a classic sign of elevated intracranial pressure. Choices A, C, and D are incorrect because they do not account for the specific neurological findings observed in this scenario.

Correct Answer: C

Rationale: The correct answer is C because discussing the potential impact of the patient's family history of stroke is crucial in understanding her risk factors. By encouraging lifestyle changes, such as maintaining a healthy diet and regular exercise, the nurse can help reduce the patient's risk of stroke. This approach aligns with preventive care and empowers the patient to take control of her health. Choices A and D are incorrect because stopping medications or recommending immediate surgery without proper assessment and consultation with healthcare providers could be harmful and unnecessary. Choice B is incorrect as family history is a known risk factor for stroke, and it is essential to address this risk factor and educate the patient on how it may impact her health.

Correct Answer: A

Rationale: The correct answer is A: Reduced anxiety. GABA is an inhibitory neurotransmitter that helps calm the brain, reducing anxiety. By potentiating GABA's action, the medication would enhance its calming effect, leading to reduced anxiety. Improved memory (B), more organized thinking (C), and fewer sensory perceptual alterations (D) are unlikely because GABA primarily influences anxiety and relaxation, not memory, cognitive organization, or sensory perception.

Correct Answer: B

Rationale: The correct answer is B, fluoxetine (Prozac), because it is an antidepressant commonly used to treat major depression. The nurse should provide teaching about its dosage, side effects, and potential interactions. Chlordiazepoxide (A) is a benzodiazepine used for anxiety, not depression. Clozapine (C) is an antipsychotic used for schizophrenia, not depression. Tacrine (D) is used for Alzheimer's disease, not depression. Therefore, options A, C, and D are incorrect for teaching a patient hospitalized for major depression.

Correct Answer: B

Rationale: The correct answer is B because SSRIs work by blocking the reuptake of serotonin at the presynaptic neuron. This leads to more serotonin being available in the synaptic gap, which enhances neurotransmission and helps alleviate depression symptoms. Choices A, C, and D are incorrect because SSRIs do not destroy neurotransmitters, increase production of acetylcholine and dopamine, or block muscarinic and alpha1-norepinephrine receptors.