체험은 만족하셨나요?
방금 푼 그 흐름,
합격까지 이어보세요
지식 자료를 소장하고 멋진 의료인으로 성장하세요
학습 자료 둘러보기 →A child who was briefly unconscious after head trauma and is now awake remains at risk for a lucid interval, a period of stability before rapid deterioration from an expanding epidural hematoma. The nurse's highest priority is detecting signs of brainstem compression.
The most critical finding is anisocoria (unequal pupils) with a sluggish response to light. This is a late sign of uncal herniation, where a mass compresses the oculomotor nerve (CN III). The parasympathetic fibers on the nerve's surface are affected first, causing ipsilateral pupil dilation and fixation. This is a neurosurgical emergency requiring immediate reporting to prevent irreversible brainstem damage.
Do not be falsely reassured by normal or near-normal vital signs. Cushing's triad (bradycardia, hypertension, irregular respirations) is a very late and often unreliable sign in children. A heart rate of 120 bpm in a crying 4-year-old is expected and does not rule out a life-threatening intracranial lesion.
학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.