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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Wear compression stockings daily." is not specifically related to preventing diabetic complications of the eyes and kidneys.
B. "Examine your feet carefully every day." is important for preventing diabetic foot ulcers but is not directly related to preventing retinopathy and nephropathy.
C. Maintaining stable blood glucose levels is the most effective way to prevent complications like retinopathy and nephropathy in clients with diabetes mellitus. Consistently high blood glucose levels can lead to damage to blood vessels in the eyes and kidneys.
D. "Have an eye examination once per year." is important, but maintaining stable blood glucose levels is the most effective long-term prevention strategy.
Correct Answer is A
Explanation
A. Flashes of light and floaters are common early symptoms of retinal detachment as the retina begins to pull away from the underlying tissue.
B. Retinal detachment is usually painless; pain with eye movement is more associated with other eye conditions.
C. Increased glare is not typically associated with retinal detachment but may occur in cataracts.
D. Redness is usually a sign of conjunctivitis, not retinal detachment.
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