# A nurse is conducting a neurological assessment on a 22-year-old patient admitted after a motor vehicle accident with suspected head injury. Which assessment finding would be most indicative of increased intracranial pressure (ICP)? > source: MyMerci (mymerci.kr) > url: https://mymerci.kr/pages/nclex_q.php?qn_id=542747 > language: ko > subject: Fundamentals ## 문제 A nurse is conducting a neurological assessment on a 22-year-old patient admitted after a motor vehicle accident with suspected head injury. Which assessment finding would be most indicative of increased intracranial pressure (ICP)? ## 보기 1. Pupils that are equal, round, and reactive to light (PERRL) with brisk response 2. Unequal pupils with one pupil dilated and sluggish to react to light **✔ 정답** 3. Patient oriented to person and place but confused about time 4. Mild tremor in both hands when arms are extended **정답: 2** ## 해설 Unequal pupils with dilation and sluggish light response indicate increased intracranial pressure affecting cranial nerve III, requiring immediate intervention. Other findings like normal pupils, confusion, or tremor are less urgent. ## 심화 해설 Correct Answer: Unequal pupils with one pupil dilated and sluggish to react to light Explanation: In a patient with a suspected head injury, the development of unequal pupils, where one is dilated and reacts sluggishly to light, is a critical and late sign of significantly increased intracranial pressure (ICP). This finding, often referred to as a unilaterally fixed and dilated pupil or "blown pupil," represents a neurological emergency. The underlying mechanism involves rising ICP causing the brain tissue to shift, which compresses the oculomotor nerve (cranial nerve III) against the tentorium or the clivus. The parasympathetic fibers that control pupillary constriction run on the outside of this nerve and are highly susceptible to compression. When these fibers are impaired, the pupil on the affected side loses its ability to constrict, resulting in dilation and a sluggish or absent reaction to light. The provided research underscores the critical importance of precise pupillary assessment in this context. The study by Chen et al. introduces the Neurological Pupil index (NPi) as a sensitive measure for detecting early changes in pupil reactivity, which can be an early indicator of increasing ICP in patients with severe traumatic brain injury (TBI) [1]. While the NPi technology provides a quantitative and highly sensitive measure, the clinical finding of a grossly unequal and sluggish pupil, as described in the correct option, is a well-established and ominous sign that demands immediate intervention. It indicates that the compensatory mechanisms for ICP have been exhausted and brainstem herniation may be imminent. Analysis of Incorrect Options: * Option 1: Pupils that are equal, round, and reactive to light (PERRL) with brisk response is a normal and expected finding in a healthy neurological exam. It indicates that the midbrain and cranial nerve III functions are intact and there is no significant pressure effect. This finding would be reassuring but does not indicate increased ICP. * Option 3: Patient oriented to person and place but confused about time represents a subtle change in orientation. While any alteration in mental status following a head injury is concerning and requires thorough evaluation, confusion about time alone is a relatively mild cognitive deficit. It is a non-specific sign that could be caused by many factors, including concussion, metabolic disturbances, or early-stage increased ICP. It is not as specifically localizing or as immediately life-threatening as a unilateral pupillary change. * Option 4: Mild tremor in both hands when arms are extended is a motor finding that suggests a problem with the cerebellum, basal ganglia, or metabolic issues. A postural tremor is not a classic or primary sign of increased ICP. While ICP can eventually cause motor posturing (decorticate or decerebrate), a mild bilateral tremor is not a direct indicator of the pressure dynamics occurring inside the skull after a traumatic injury.References (research sources) - [1]Pupillary reactivity as an early indicator of increased intracranial pressure: The introduction of the Neurological Pupil index.Research articleChen JW, Gombart ZJ, Rogers S, Gardiner SK, Cecil S, Bullock RM. (2011) · DOI: 10.4103/2152-7806.82248 ## 임상 시나리오 Clinical Assessment for Increased ICP In a patient with a suspected head injury, perform serial neurological assessments focusing on the level of consciousness, pupillary reactivity, and motor function. A unilaterally dilated and sluggish pupil is a late, ominous sign of uncal herniation and requires immediate intervention. Pupillary Assessment Technique - Use a bright, focused penlight in a dimly lit room to assess each pupil individually. - Note the size (in millimeters), shape, and equality of the pupils. - Assess the direct and consensual light reflex, documenting the speed of reaction as brisk, sluggish, or fixed. - Any change from baseline, particularly a new onset of unilateral dilation with sluggish response, must be reported immediately to the provider. Emergency Nursing Actions If a blown pupil is identified, the priority is to notify the physician or rapid response team immediately while maintaining the patient's head in a neutral midline position to promote venous outflow. Ensure the airway is protected, administer supplemental oxygen, and prepare for emergency interventions such as hyperosmolar therapy (mannitol or hypertonic saline) and possible surgical decompression. ## 핵심 개념 - **Blown Pupil** — A unilaterally fixed and dilated pupil resulting from compression of the oculomotor nerve, indicating a late-stage neurological emergency such as uncal herniation. - **Oculomotor Nerve (CN III)** — The third cranial nerve responsible for pupillary constriction and most eye movements; its parasympathetic fibers are susceptible to compression from increased ICP. - **Neurological Pupil Index (NPi)** — A quantitative, objective measure of pupil reactivity used as an early, sensitive indicator of neurological change in patients with severe traumatic brain injury. - **Uncal Herniation** — A life-threatening shift of brain tissue where the medial temporal lobe is pushed across the tentorium, compressing the oculomotor nerve and brainstem. ## 같은 주제 문제 - [A nurse is conducting a neurological assessment on a 68-year-old patient admitted with alt…](https://mymerci.kr/pages/nclex_q.php?qn_id=542745) - [A nurse is conducting a neurological assessment on a 68-year-old patient admitted with alt…](https://mymerci.kr/pages/nclex_q.php?qn_id=542746) --- More free questions: [기출문제](https://mymerci.kr/) _학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요._