The nurse is closely monitoring a child who is unconscious after a fall and notices that he suddenly has a fixed and dilated pupil.How should the nurse interpret this finding?
A) Eye trauma
B) Neurosurgical emergency
C) Severe brainstem damage
D) Indication of brain death

Question

Quizplus · Accepted Answer

Pupils that suddenly appear fixed and dilated indicate 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 neurological insult.Pinpoint pupils or bilateral pupils that remain fixed 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