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 D
Explanation
A. Avoid friction over scaly lesions while bathing is generally good advice, but it is not the primary focus in this situation.
B. Eliminate the use of products containing salicylic acid is not necessary unless the client has a known sensitivity or reaction to it, as salicylic acid is commonly used to treat psoriasis.
C. Maintain occlusive dressings on the lesions throughout the day and remove them at bedtime is not typically recommended for psoriasis, as it can exacerbate the condition or increase irritation. Topical treatments, if prescribed, should be used as directed.
D. Psoriasis is often exacerbated by stress. Therefore, teaching the client effective stress reduction techniques (e.g., meditation, deep breathing, yoga) can help in managing flare-ups.
Correct Answer is D
Explanation
A. Paresthesia (numbness or tingling) is not a typical finding in cellulitis and may suggest nerve involvement or other conditions.
B. Delayed capillary refill time would indicate poor circulation or possible shock but is not a direct sign of cellulitis.
C. Pallor of the right toes could suggest circulatory issues but is not associated with cellulitis.
D. Cellulitis is an infection of the skin and underlying tissues, usually presenting with warmth (hot), tenderness, redness, and swelling (edema) at the site of infection.
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