During a neurologic assessment, the nurse notes a patient has a unilateral, dilated, and nonreactive pupil. This is a sign that the patient is experiencing pressure on which cranial nerve?
a. I
b. II
c. III
d. IV
ANS: C
The third cranial nerve runs parallel to the brainstem. The function of the oculomotor nerve is essential for eye movements. A traumatic brain injury can result in increased intracranial pressure, edema to the brainstem with pressure on cranial nerve III, causing the ominous sign of a unilateral, dilated, and nonreactive pupil.
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