During initial assessment of a client who has just suffered a head injury, a nurse notes that the pupils have an ovoid appearance. What is the nurse's best first action?
A. Anticipate intervention for increased ICP after notifying the physician.
B. Document the finding after completing a full physical assessment.
C. Place the client in Trendelenburg position after ensuring that the blood pressure is normal.
D. Evaluate visual acuity and accommodation after verifying this finding with another nurse.
A
The change in pupil appearance from round to ovoid (mid-stage between normal and dilated) is an indication of increase intracranial pressure and must be reported to the physician immediately.
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