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.
You might also like to view...
The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). What significant information would the nurse include?
a. Wrapping the infant snugly for rest periods b. Positioning the infant prone for sleep c. Sitting the infant up in an infant seat d. Placing infants on their backs or sides for sleep
The nurse is preparing to clean a deep wound. What cleaning solution is the safest for all wounds?
A) Normal saline B) Povidone-iodine C) Dakin's solution D) Hydrogen peroxide
The nurse is admitting and preparing the client for surgery. Following administration of Ativan 2 mg orally, one time dose, which safety measure is most appropriate?
A) Place the client in a semi-Fowler's position. B) Place the side rails in the up position. C) Remove the water pitcher from the bedside. D) Instruct the family to call for any client needs.
Clinical operation disruption is can be minimized through which of the following?
1. Identification of the processes and their changes are included in training. 2. Following the IT liaison's demands for perfection 3. Making the changes during the night shift 4. Spending money on a consultant.