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.
B)Neurosurgical emergency.
C)Severe brainstem damage.
D)Indication of brain death.

Question

Quizplus · Accepted Answer

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.

The Nurse Is Closely Monitoring a Child Who Is Unconscious