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.How should the nurse interpret this?
A) Eye trauma
B) Brain death
C) Severe brainstem damage
D) Neurosurgical emergency

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.One fixed and dilated pupil is not suggestive of brain death.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.

The Nurse Is Closely Monitoring a Child Who Is Unconscious