A patient was admitted to the emergency department after falling at work. The nurse assesses that the patient's left pupil has a slightly oval shape. What nursing action is indicated?
1. Notify the physician immediately.
2. Document this finding as anisocoria.
3. Document a normal finding
4. Plan to reassess the pupils in a darker room.
1
Rationale 1: Oval shaping of one pupil can indicate potential brain stem herniation. The physician should be notified immediately.
Rationale 2: Anisocoria is unequal pupil size without pathology. The nurse cannot be certain there is no pathology.
Rationale 3: This is not a normal finding.
Rationale 4: Reassessment is not necessary.
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