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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Brain cells begin to die within 2 minutes if blood flow is interrupted, which is why rapid intervention is crucial during a stroke or other conditions that block cerebral blood flow.
A. 8 minutes is too long for brain cells to survive without oxygen.
C. 20 minutes is too long for brain cells to survive without oxygen.
D. 5 minutes is too long for brain cells to survive without oxygen.
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.
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