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A patient who sustained a head injury in a motor vehicle crash several days ago has been active and talkative, and headaches have been well controlled with acetaminophen. When performing the daily assessment, the nurse observes increased dilation of the patient's pupils and notes a sluggish response to light. Which action is correct?

a) Administer an analgesic
b) Document the findings
c) Notify the healthcare provider
d) Increase the dose of acetaminophen

1 Answer

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Final answer:

The correct action when a patient with a head injury shows increased pupil dilation and a sluggish light response is to notify the healthcare provider, as it may indicate a serious issue such as expanding brain injury. Acetaminophen should be administered within recommended dosages to avoid liver damage.

Step-by-step explanation:

When a patient who has sustained a head injury exhibits increased pupil dilation and a sluggish response to light, this could signify a change in intracranial pressure or potential brain injury. The appropriate action in this scenario would be c) Notify the healthcare provider because these symptoms could indicate a serious complication, such as an expanding hematoma, which requires immediate medical attention. Continuing to observe and document the findings is important but needs to be carried out after informing the healthcare provider. It is not advisable to increase the dose of acetaminophen or administer additional analgesia without medical consultation, as doing so could mask symptoms or cause harm, especially if an overdose occurs leading to liver damage.

Key points to remember when administrating acetaminophen are to not exceed the recommended dose due to risk of liver damage and to ensure appropriate dosing in children. When a patient displays new or worsening neurological signs, prompt evaluation and intervention are critical to optimal outcomes, which is aligned with the practices described on the referenced neurologic exam website.

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