During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes:
a. Is a normal occurrence.
b. May indicate disease of the cerebellum or brainstem.
c. Is a sign that the patient is nervous about the examination.
d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.
ANS: B
End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.
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