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?

Movement of the eye in the sideward direction occurs, with neck extension

When flexing the neck, eye movement is in the upward direction

Movement of the eye is in the opposite direction of the turned head

When extending the neck, eye movement is in the downward direction

Answer and Explanation

The Correct Answer is C

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.

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Correct Answer is A

Explanation

A. After retinal detachment surgery, it is essential to restrict head movement to avoid further damage to the retina or to ensure proper healing post-surgery.
B. Apply cool compresses is not typically recommended before or after retinal detachment surgery, as it could cause discomfort or worsen symptoms.
C. Keep both eyes patched is not necessary unless specifically instructed by the surgeon.
D. Eye drops to constrict the pupils are generally used after surgery but are not a preoperative measure.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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