A nurse is caring for a client who sustained a severe traumatic brain injury 48 hours ago. Which assessment finding would be the most concerning and require immediate intervention?

1 Pupils that are fixed and dilated bilaterally ✓ 정답
2 Glasgow Coma Scale score decrease from 8 to 6
3 Intracranial pressure reading of 22 mmHg
4 Blood pressure of 160/90 mmHg with bradycardia

해설

Fixed and dilated pupils bilaterally indicate severe brainstem compression and impending herniation, requiring immediate intervention. Other findings (GCS decrease, ICP elevation, Cushing's triad) are serious but less emergent.

같은 주제 다음 문제A nurse is caring for a client who sustained a severe traumatic brain injury 6 hours ago. …

심화 해설

Clinical Priority and Pathophysiology

The finding of bilaterally fixed and dilated pupils in a client with severe traumatic brain injury (sTBI) represents a catastrophic neurological event. This sign indicates a failure of the oculomotor nerve (CN III) due to compression, most commonly from uncal herniation. When intracranial pressure (ICP) rises critically, the medial temporal lobe (uncus) herniates over the tentorial edge, compressing the parasympathetic fibers running along the surface of CN III. This compression blocks the pupillary light reflex, causing the pupils to become non-reactive and dilated. Bilateral involvement signifies that the pressure gradient is affecting the brainstem bilaterally, which is a preterminal sign of brainstem failure and imminent respiratory and cardiac arrest. This demands an immediate, emergent response to attempt to lower ICP, as it signals irreversible brain damage is occurring.

Analysis of Other Options

While all options are concerning in the context of sTBI, they do not represent the same level of immediate, irreversible threat as bilateral fixed and dilated pupils.

- Option 2: Glasgow Coma Scale score decrease from 8 to 6. A drop in the GCS is a critical finding that indicates neurological deterioration and requires urgent reporting and intervention. However, it is an earlier warning sign. The GCS can fluctuate and a score of 6, while indicating severe coma, still leaves room for potential intervention before irreversible brainstem damage occurs. The bilaterally fixed and dilated pupils are the endpoint of the deteriorating pathway that a falling GCS warns about.

- Option 3: Intracranial pressure reading of 22 mmHg. This ICP value is above the normal threshold (typically

임상 시나리오

Recognizing Terminal Herniation in TBIBilateral Fixed and Dilated Pupils as a Preterminal Sign

In severe traumatic brain injury, bilaterally fixed and dilated pupils are the most critical finding, indicating uncal herniation with compression of the oculomotor nerve (CN III) and brainstem. This signals imminent, irreversible brainstem failure and requires an immediate, emergent response to lower intracranial pressure (ICP).

Prioritize interventions by recognizing the progression of deterioration. A drop in Glasgow Coma Scale (GCS) is an early warning, and an ICP reading above 20 mmHg is a treatable threshold. The presence of Cushing's triad (hypertension, bradycardia, irregular respirations) is a late sign, but bilateral fixed pupils represent the most advanced and immediately life-threatening stage.

Caution

Do not confuse a unilateral fixed pupil with the bilateral presentation. A unilateral fixed pupil is a critical early herniation sign requiring urgent action, but bilateral involvement confirms a catastrophic, often irreversible, brainstem injury demanding the highest priority.

핵심 개념

Brain Herniation (뇌탈출) — Brain tissue deviates from its normal position due to pressure gradients within the cranial cavity and herniates through openings in the skull (e.g., tentorial notch), a life-threatening condition. Pupil dilation occurs due to compression of the oculomotor nerve (CN III).
Increased Intracranial Pressure (ICP) (두개내압 상승) — A condition where the pressure inside the cranial cavity rises above the normal range (5-15 mmHg in adults). It can be caused by brain tumors, hemorrhage, edema, trauma, etc., and may lead to brain herniation.
Cushing's Triad (쿠싱 삼징) — Classic signs of severe increased intracranial pressure, including elevated systolic blood pressure, bradycardia, and irregular breathing (abnormal respirations). This is a compensatory response of the autonomic nervous system to maintain cerebral perfusion.
Pupillary Light Reflex (동공 대광 반사) — Pupillary constriction response to light. This is an important indicator for assessing the function of the oculomotor nerve (CN III). A fixed and dilated pupil indicates direct compression of the oculomotor nerve or brainstem injury.
Glasgow Coma Scale (GCS) (글래스고 혼수 척도) — A tool for objectively assessing level of consciousness. It evaluates three categories: eye opening (4 points), verbal response (5 points), and motor response (6 points), with a total score ranging from 3 (worst) to 15 (normal). A score of 8 or below generally indicates severe brain injury.

Merci NCLEX-RN Question Bank 3,445 문제 · 로그인 없이 바로 볼 수 있어요

마이메르시로 국가고시 완벽 대비

기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요.

무료로 시작하기

App Store Google Play

학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요.

성장을 멈추지 마세요

A nurse is caring for a client who sustained a severe traumatic brain injury 48 hours ago. Which assessment finding would be the most concerning and require immediate intervention?

심화 해설

임상 시나리오

핵심 개념

마이메르시로 국가고시 완벽 대비