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 A
Explanation
A. The priority in managing delirium is ensuring the patient's safety, as delirium increases the risk of falls, self-harm, and other dangerous behaviors. Close monitoring and protective measures are essential.
B. Oxygenation is important but not the first priority unless the patient shows signs of hypoxia or respiratory distress.
C. Pain management should be considered, but it is secondary to addressing the safety risks associated with delirium.
D. Infection should be investigated, but the immediate concern in delirium is safety due to the altered mental state.
Correct Answer is A
Explanation
A. The constriction and dilation of blood vessels in the brain helps maintain appropriate cerebral blood flow and cerebral perfusion pressure (CPP) despite fluctuations in blood pressure.
B. Catecholamines regulate other systemic body functions, but they do not directly impact cerebral perfusion pressure.
C. Carbon dioxide exhalation can affect blood flow, but the primary regulation of CPP is through blood vessel constriction and dilation.
D. The amount of blood pumped from the heart can impact overall blood pressure but does not directly regulate cerebral perfusion pressure.
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