The nurse will include which intervention for the patient newly admitted with cellulitis of the right foot?

Encourage frequent ambulation

Maintain foot in a dependent position.

Apply warm, moist heat

Wrap the foot snugly in the blanket

Answer and Explanation

The Correct Answer is C

A.   Ambulation may worsen the condition as it could increase swelling or spread infection.
B.   This may increase swelling and should generally be avoided in cellulitis.
C.   This helps to improve circulation and reduce swelling in cellulitis.
D.   Wrapping the foot tightly could exacerbate swelling and discomfort.

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Correct Answer is C

Explanation

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.

A. CNV B. CN VIII C. CN IV D. CN III

Correct Answer is D

Explanation

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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The nurse will include which intervention for the patient newly admitted with cellulitis of the right foot?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

For the patient who wears contact lenses, which intervention would the nurse teach the patient when diagnoses with bacterial conjunctivitis?

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?

Which refractive error describes the vision of a patient for whom nearby objects are clear but objects at a distance are blurred?

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?

Which laboratory result would the nurse anticipate when reviewing the cerebrospinal fluid analysis of a patient with bacterial meningitis?

The nurse will include which intervention for the patient newly admitted with cellulitis of the right foot?

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse plan to include in the plan of care? (Select All that Apply.)