Practice Question
A patient presents to the emergency room after being found on the ground at home. The nurse assesses the patient's pupil response and finds them to be fixed and dilated. The nurse knows this is caused by what mechanism?
Answer Choices:
Correct Answer:
Brainstem hypoxia.
Rationale:
🧠Fixed, dilated pupils reflect failure of parasympathetic (Edinger–Westphal) output via cranial nerve III, a function integrated in the midbrain/upper brainstem.
🧠Brainstem hypoxia depresses these pupillary light reflex pathways, producing areflexic, dilated pupils—often bilateral in global ischemia or severe herniation syndromes.
🧠Loss of pupillary reactivity in this context signals critical neurologic deterioration and demands rapid management of airway, oxygenation, and intracranial pressure.
🧠The presentation fits central failure of constrictor pathways rather than peripheral causes and is a grave sign warranting immediate escalation.
🧠Continuous neuro-checks with GCS, pupillometry, and ICP control are essential to prevent secondary brain injury.
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This question is from ☑️ NR412-EXAM4 which contains 50 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Pathophysiology
- Answer Choices: 4