The nurse is assessing the client's pupillary responses. The client is found to have no consensual response. The finding indicates which of the following to the nurse?
1. Cranial nerve III may not be functioning appropriately.
2. This is a normal finding.
3. This is evidence of increased intracranial pressure.
4. This is evidence of optic nerve damage.
1
Rationale 1: When evaluating pupillary response, the unilluminated, or consensual, pupil should also constrict. When this does not occur, it may be indicative of problems associated with cranial nerve III.
Rationale 2: This is not a normal finding.
Rationale 3: Increased intracranial pressure is associated with pupils that are unequal and irregularly shaped.
Rationale 4: This is not evidence that optic nerve damage has occurred. Optic nerve damage can produce changes in the client's visual fields.
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