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

Answer and Explanation

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.

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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.

A. Glucose level, BP, and brain tissue B. BP, brain tissue, and cerebrospinal fluid C. BP, brain tissue, body mass index D. BP, brain tissue, and ventricles of the brain

Correct Answer is B

Explanation

A. Glucose level, BP, and brain tissue: Glucose level is not a key component of ICP balance.
B. BP, brain tissue, and cerebrospinal fluid: These are the primary components that contribute to ICP balance. Changes in any of these can affect pressure inside the skull.
C. BP, brain tissue, body mass index: BMI is not directly related to ICP balance.
D. BP, brain tissue, and ventricles of the brain: The ventricles are involved in cerebrospinal fluid production but are not one of the primary components of ICP balance as a whole.

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A nurse observes a patient whose right eye is fixed and dilated, for which cranial nerve (CN) would the nurse suspect nerve compression?

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Naxlex Comprehensive Predictor Exams

when assessing a patient's neurologic status upon arrival to the emergency room, which reliable indicator would the nurse utilize first?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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