During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive,
and the left pupil is 4 mm and reacts to light. What do these findings suggest?
a.
Injury to the right eye
b.
Increased intracranial pressure
c.
Test inaccurately performed
d.
Normal response after a head injury
ANS: B
In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous. CN III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil dilation. The other responses are incorrect.
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