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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?

A.

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

B.

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

C.

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

D.

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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Related Questions

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.

Correct Answer is D

Explanation

A. BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B. BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C. BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D. The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

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