The nurse who is caring for a post-stroke client suddenly notes that the client has a fixed and dilated pupil. What would be the most appropriate action by the nurse?
The nurse who is caring for a post-stroke client suddenly notes that the client has a fixed and dilated pupil. What would be the most appropriate action by the nurse?
A. Reduce environmental stimuli.
[4%]
B. Reassess after ten minutes.
[1%]
C. Check the client’s blood pressure.
[24%]
D. Notify the physician.
[71%]
Statistics
Subject/Lesson
Subject
Adult Health
Lesson
Neurologic
Client Need
Test Plan
Reduction of Risk Potential
Related Topic
System Specific Assessments
Item Type
Item Type
Application
Explanation
Choice D is correct. A new onset fixed and dilated pupil following a stroke or a traumatic brain injury indicates acutely increased intracranial pressure (ICP). It may indicate transtentorial cerebral herniation and, if unaddressed, may result in death. This situation warrants immediate medical intervention to decrease the ICP. The nurse needs to notify the physician immediately.
Choice A is incorrect. A fixed and dilated pupil signifies an increase in ICP. Reducing environmental stimuli is not an appropriate intervention at this time.
Choice B is incorrect. There is no need to reassess after ten minutes, as any signs of increased ICP warrants immediate attention from the healthcare team.
Choice C is incorrect. The client’s blood pressure may need to be checked eventually. However, the physician must be notified first because an increased ICP requires immediate intervention.
Learning Objective
Identify that a fixed and dilated pupil warrants immediate attention because it signifies acutely increased intracranial pressure.
Related Videos
8 Key Topics
External Ventricular Drain
27.2 Critical Care Neurovascular System
Pupil Exam
16.2 Neuro Assessment
Stroke
16.5 Central Nervous System Disorders
Increased ICP
27.2 Critical Care Neurovascular System
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