During assessment, the nurse notes that a client's right pupil is 2 mm larger than the left pupil. Which is the nurse's first action?
a. Ask the client how long this condition has been present.
b. Attempt to elicit a red reflex in both eyes.
c. Document the finding as the only action.
d. Identify the medications that the client is taking.
A
Although both pupils are normally the same size and a difference in size can indicate various pathologies, approximately 5% of people have a noticeable difference in the size of their pupils. The nurse should first determine whether this condition represents a change or has been present for a long time.
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