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. Decorticate posturing indicates severe brain injury, characterized by flexion of the arms and adduction of the upper extremities.
B. Epileptic is not a term used to describe posturing related to head injury.
C. Stroke does not describe posturing.
D. Decerebrate posturing is characterized by extension and pronation of the arms, not flexion.

A. "Use simple, child-like statements when speaking." B. "Incorporate nonverbal cues in the conversation." C. "Use a higher-pitched tone of voice when speaking." D. "Ask multiple choice questions as part of the conversation."

Correct Answer is B

Explanation

A. Using child-like statements may be demeaning and does not support effective communication. It is
important to speak at the client’s level and provide respect.
B. Incorporating nonverbal cues, such as gestures, facial expressions, and pictures, can help facilitate understanding and communication with a person who has aphasia.
C. Using a higher-pitched tone of voice does not aid comprehension and may be perceived as patronizing.
D. Asking multiple-choice questions is helpful, but it is not the most general approach. Using clear, simple language with nonverbal cues is more beneficial.

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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

Which term would the nurse use to document a patient who is comatose from a head injury and display flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities?

Correct Answer is A

Explanation

A nurse is caring for a client who has aphasia following a stroke. A family member asks the nurse how she should communicate with the client. Which of the following responses by the nurse is appropriate?

Correct Answer is B

Explanation

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?

Which refractive error describes the vision of a patient for whom nearby objects are clear but objects at a distance are blurred?

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A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care? (Select All that Apply.)

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A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?