A nurse observes a patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression?

CNV

CN VIII

CN IV

CN III

Answer and Explanation

The Correct Answer is D

A.   CN V (Trigeminal nerve) is responsible for sensation in the face and motor function for chewing, not eye movement or pupil constriction.
B.   CN VIII (Vestibulocochlear nerve) deals with hearing and balance, not eye function.
C.   CN IV (Trochlear nerve) controls eye movement, but it does not typically affect the pupil in this way.
D.   Cranial nerve III (Oculomotor nerve) controls most eye movements and pupil constriction. A fixed and dilated pupil typically indicates damage to CN III, which may be due to nerve compression, often from increased intracranial pressure or herniation.

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Correct Answer is C

Explanation

A. The oculocephalic reflex test should cause the eyes to move in the opposite direction to the head turn, indicating intact brainstem function.
B. Movement of the eyes in an upward direction upon neck flexion indicates an abnormal response, suggesting a lesion.
C. A lesion could result in abnormal eye movement, as the eyes should move opposite to head movement.
D. Eye movement in the downward direction during neck extension is not a normal response and suggests a brainstem issue.

A. Increased ICP B. Decreased cerebral blood flow (CBF) C. Increased cerebral perfusion pressure (CPP) D. Normal intracranial pressure

Correct Answer is B

Explanation

A. Increased ICP would be a concern when the MAP falls below 70 mm Hg because reduced blood pressure can lead to inadequate cerebral blood flow and worsen ICP.
B. Decreased cerebral blood flow (CBF) is also a concern with low MAP, but the priority is maintaining MAP at a sufficient level to ensure adequate perfusion.
C. Increased CPP is unlikely with a low MAP, as CPP is a product of MAP and ICP.
D. Normal ICP would be a good outcome; however, with a low MAP, the nurse should be concerned about insufficient cerebral perfusion and the risk of increased ICP.

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A nurse observes a patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After performing an assessment of the oculocephalic reflex, the nurse suspects that the patient has an intracranial lesion. Which patient behavior supports the nurse's assessment findings?

Correct Answer is C

Explanation

Which outcome would concern the nurse when the patient's calculated mean arterial pressure (MAP) is below 70 mm Hg?

Correct Answer is B

Explanation

A nurse observes a patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression?

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