The nurse is assessing a patient for neurological changes after a head trauma. Which eye assessment should the nurse perform?
Select all that apply.
1. ptosis
2. extraocular movements
3. accommodation
4. color of iris
5. nystagmus
Correct Answer: 1, 2, 3, 5
Ptosis refers to the drooping one eyelid and may indicate cranial nerve damage. Failure of one or both eyes to follow an object in any given direction may reflect cranial nerve dysfunction. Accommodation is the bending of light rays at the lens so that they focus on one point on the retina. Failure of accommodation, along with lack of pupil response to light, may signal a neurologic problem. Nystagmus is the involuntary rhythmic movement of the eyes that occurs with neurologic disorders and the use of some medications. The color of the iris does not reflect neurologic changes or deficits in cranial nerves.
You might also like to view...
A client is prescribed a CNS stimulant as treatment for respiratory depression. Before administering the drug, which of the following would be most important for the nurse to assess? Select all that apply
A) Blood pressure B) Pulse C) Respiratory rate D) Respiratory pattern E) Review of recent lab work
An outcome analysis yields information about the net effects of an intervention
A) True B) False
A nurse is caring for a client with urine retention who has been catheterized. What is the maximum amount of urine that can be removed from the bladder?
A) 750 to 1,000 mL B) 1,000 to 1,250 mL C) 1,250 to 1,500 mL D) 1,500 to 1,750 mL
Identify the mechanism of action of antacids.
A. Stimulating the production of gastric acid B. Reducing the concentration of gastric acid C. Reducing the volume of gastric acid D. Neutralizing gastric acid