The nurse is assisting with caloric testing on a patient who is persistently unconscious. Which response would the nurse expect if severe brainstem injury exists?

1. No response
2. Right beating nystagmus to cold water introduced in the right ear
3. Left beating nystagmus to introduction of warm water in the left ear
4. Nystagmus in both eyes with introduction of warm or cold water in either ear


1
Rationale 1: If the patient has a severe brainstem injury, there will be no response to caloric testing.
Rationale 2: The patient with severe brainstem injury will not have this response.
Rationale 3: The patient with severe brainstem injury will not have this response.
Rationale 4: The patient with severe brainstem injury will not have this response.

Nursing

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