The nurse is going to assist with the assessment of a patient's oculovestibular reflex. What should be done before this reflex is assessed?
1. Ensure that the patient's spinal cord has been found intact.
2. Ensure that the patient has an intact gag reflex.
3. Determine that the patient can tolerate being in the supine position.
4. Determine that the patient has an intact tympanic membrane.
4
Rationale 1: It is not necessary to ensure that the patient's spinal cord has been found intact.
Rationale 2: It is not necessary to ensure that the patient has an intact gag reflex before assessing this reflex.
Rationale 3: The head of the patient's bed is elevated 30 degrees when testing this reflex.
Rationale 4: The oculovestibular reflex, or cold calorics, is performed only after determining that the tympanic membrane is intact. The head of the patient's bed is elevated 30 degrees, and then 50 mL of cool saline is injected into an ear.
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