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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Unable to discriminate words and letters is associated with left hemisphere damage, which is more linked to language and communication deficits.
B. Deficits in the right visual field would typically occur with left hemisphere damage, which affects vision.
C. Motor retardation is more often associated with left hemisphere damage affecting motor control.
D. Right cerebral hemisphere damage often results in behavioral changes, such as poor impulse control, lack of awareness of deficits (anosognosia), and changes in emotional responses.
Correct Answer is ["A","B","D"]
Explanation
A. Decreasing Glasgow Coma scores indicate a worsening neurological status and reduced consciousness.
B. Swelling of the optic nerve (papilledema) is a sign of increased ICP and indicates worsening conditions.
C. A respiratory rate of 12/min may be within normal range for some individuals but can also be a sign of impending respiratory depression in cases of severe ICP. However, it is not as immediately concerning as the other options in this case.
D. Changes in pupil size and shape are classic signs of worsening ICP. Unequal or nonreactive pupils are a key indicator.
E. Blood pressure of 108/74 mm Hg is not concerning unless it represents a significant drop from the baseline; other signs of worsening ICP are more critical in this case.
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