During neuro checks on a client with a head injury, the nurse finds a newly fixed and dilated right pupil. What does this suggest?

A. Effects of eye drops only
B. A normal finding after head injury
C. Improvement in the client's condition
D. Increasing intracranial pressure with possible brain herniation

Show answer and rationale

Correct answer: D

A new unilateral fixed, dilated pupil suggests compression of cranial nerve III from herniation. This is an emergency requiring immediate notification.

Source: Lewis's Medical-Surgical Nursing, 13th ed. (head injury)

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This question is one of 113 Reduction of Risk Potential items in NCLEXSim. On the NCLEX-RN, this category makes up 9–15% of the exam.

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During neuro checks on a client with a head injury, the nurse finds a newly fixed and dilated right pupil. What does this suggest?

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