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Assessing head and neck Exam 2025 Questions and Answers An intensive care nurse is caring for a client who sustained a head injury from a motor vehicle accident. During the morning assessment, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 3 mm and reacts to light. What is the nurse's priority action? - --Answer --Notify the health care provider immediately Rationale:Decreased or absent pupillary response and uneven pupil dilation indicate blindness or increased cranial pressure and serious brain damage. The nurse would notify the health care provider immediately, because this is a critical change in condition. The nurse should not wait for 1 hour to reassess, because the client's condition will continue to deteriorate and brain damage could increase. Monitoring the client's breathing is important, but not the nurse's priority concern. Repositioning the client will not help to reduce the cranial pressure. ....COPYRIGHT ©️ 2025 ALL RIGHTS RESERVED...TRUSTED & VERIFIED 1