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 A

Explanation

A. Shivering is a common response to cold therapy (such as a hypothermia blanket) as the body attempts to maintain its core temperature. This can increase metabolic demands and oxygen consumption, which should be closely monitored.
B. Seizures are not typically associated with the use of hypothermia blankets unless there are underlying conditions that predispose to them.
C. Dehydration could occur with any prolonged therapy but is not the immediate concern with hypothermia blankets.
D. Burns are rare but could occur if the hypothermia blanket is not properly managed. Shivering is a more immediate concern.

A. Dim vision. B. Papilledema C. Body temperature D. Level of consciousness

Correct Answer is D

Explanation

A. Dim vision could be a sign of many conditions but is not the first indicator the nurse should assess for neurologic status.

B. Papilledema (swelling of the optic disc) is a late sign of increased intracranial pressure and is not immediately available on assessment.
C. Body temperature is important but not as directly related to the neurological status as LOC.
D. The level of consciousness (LOC) is one of the most important initial indicators of a patient's neurologic status, as it helps assess brain function and the severity of potential neurological injury. A decrease in LOC can indicate significant brain injury or dysfunction.

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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

A nurse is caring for a client who has meningitis, a temperature of 39.7° C (103.5° F), and is prescribed a hypothermia blanket. While using this therapy, the nurse should know that the client must carefully be observed for which of the following complications?

Correct Answer is A

Explanation

when assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first?

Correct Answer is D

Explanation

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