Difficulty: Medium
Average Score: 81%
Full-length
The nurse is caring for clients on the neurology unit. What would be the MOST appropriate action for the nurse to take after noting that a client suddenly developed a fixed and dilated pupil?
Correct answer
D
Rationale
A fixed and dilated pupil is a neurological emergency, often indicating increased intracranial pressure (ICP) or brain herniation. Immediate physician notification is critical for timely intervention. Reassessing in five minutes delays care, checking visual acuity is irrelevant, and lowering the bed could worsen ICP.