The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which of the following assessment findings would be considered an emergency?

Question

1. weak hand grasps bilaterally
2. fine crackles auscultated bilateral lung bases
3. urine output 36 cc per hour
4. fixed and dilated pupil on the side of the injury

Answer 1

4

Rationale: Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation. Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Fine crackles auscultated bilateral lung bases might be due to immobility and not necessarily a change in the patient's neurological status. Urine output of 36 cc per hour would be a normal urine output requiring no intervention.