C HAPTER 16: N EUROLOGIC C LINICAL
A SSESSMENT AND D IAGNOSTIC P ROCEDURES
Urden: Priorities in Critical Care Nursing, 8th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient who has sustained a traumatic head
injury. The practitioner has asked the nurse to test the patient’s
oculocephalic reflex. Which findings indicate that the patient has an
intact oculocephalic reflex?
a. Patient’s eyes move in the same direction as the patient’s head
when turned.
b. Patient’s eyes move in the opposite direction as the patient’s head
when turned.
c. Patient’s eyes move in opposite directions from each other when
the patient’s head is turned.
d. Patient’s eyes move up and down and then back and forth when
the patient’s head is turned.
ANS: B
To assess the oculocephalic refle x, the nurse holds the patient’s eyelids
open and briskl y turns the head to one side while observing the eye
movements and then briskl y turns the head to the other side and
observes. If the eyes deviate to the opposite direction in which the
head is turned, doll’s eyes are present, and the oculocephalic reflex arc
is intact. If the oculocephalic reflex arc is not intact, the reflex is
absent.
, PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Assessment TOP: Neurologic Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Health Promotion and Maintenance
2. The nurse is precepting a new graduate nurse. The new graduate asks
about testing the oculovestibular reflex. What should the nurse tell the
new graduate?
a. “The test should not be performed on an unconscious patient
because of the risk of aspiration.”
b. “An abnormal response is manifested by conjugate, slow, tonic
nystagmus, deviating toward the irrigated ear.”
c. “This test should be included in the nursing neurologic
examination of a p atient with a head injury.”
d. “This test is performed by the practitioner and one of the final
clinical assessments of brainstem function.”
ANS: D
The oculovestibular reflex is one of the final clinical assessments of
brainstem function and is onl y perform ed by a practitioner. In a normal
response, eye movement is in the direction of the injection site. An
abnormal response is disconjugate eye movement, which indicates a
brainstem lesion, or no response, which indicates little to no brainstem
function.
PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Assessment TOP: Neurologic Clinical
, Assessment and Diagnostic Procedures MSC: NC LEX:
Health Promotion and Maintenance
3. The nurse is caring for a patient with a head injury and observes a
rhythmic increase and decrease in the rate and depth of respiration
followed by brief periods of apnea. What should the nurse document
under breathing pattern?
a. Central neurogenic hyperventilation
b. Apneustic breathing
c. Ataxic respirations
d. Cheyne-Stokes respi rations
ANS: D
Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo
of rate and depth of respiration, including brief periods of apnea. These
respirations are usuall y seen with bilateral deep cerebral lesions or
some cerebellar lesions. C entral neurogenic hyperventilations are very
deep, very rapid respirations with no apneic periods. They are usuall y
seen with lesions of the midbrain and upper pons. Apneustic breathing
includes clusters of irregular, gasping respirations separated by long
periods of apnea. They are usuall y seen in lesions of the lower pons or
upper medulla. Ataxic respirations are irregular, random patterns of
deep and shallow respirations with irregular apneic periods. They are
usuall y seen in lesions of the medulla.
PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Diagnosis TOP: Neurologic Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Health Promotion and Maintenance
A SSESSMENT AND D IAGNOSTIC P ROCEDURES
Urden: Priorities in Critical Care Nursing, 8th Edition
MULTIPLE CHOICE
1. The nurse is caring for a patient who has sustained a traumatic head
injury. The practitioner has asked the nurse to test the patient’s
oculocephalic reflex. Which findings indicate that the patient has an
intact oculocephalic reflex?
a. Patient’s eyes move in the same direction as the patient’s head
when turned.
b. Patient’s eyes move in the opposite direction as the patient’s head
when turned.
c. Patient’s eyes move in opposite directions from each other when
the patient’s head is turned.
d. Patient’s eyes move up and down and then back and forth when
the patient’s head is turned.
ANS: B
To assess the oculocephalic refle x, the nurse holds the patient’s eyelids
open and briskl y turns the head to one side while observing the eye
movements and then briskl y turns the head to the other side and
observes. If the eyes deviate to the opposite direction in which the
head is turned, doll’s eyes are present, and the oculocephalic reflex arc
is intact. If the oculocephalic reflex arc is not intact, the reflex is
absent.
, PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Assessment TOP: Neurologic Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Health Promotion and Maintenance
2. The nurse is precepting a new graduate nurse. The new graduate asks
about testing the oculovestibular reflex. What should the nurse tell the
new graduate?
a. “The test should not be performed on an unconscious patient
because of the risk of aspiration.”
b. “An abnormal response is manifested by conjugate, slow, tonic
nystagmus, deviating toward the irrigated ear.”
c. “This test should be included in the nursing neurologic
examination of a p atient with a head injury.”
d. “This test is performed by the practitioner and one of the final
clinical assessments of brainstem function.”
ANS: D
The oculovestibular reflex is one of the final clinical assessments of
brainstem function and is onl y perform ed by a practitioner. In a normal
response, eye movement is in the direction of the injection site. An
abnormal response is disconjugate eye movement, which indicates a
brainstem lesion, or no response, which indicates little to no brainstem
function.
PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Assessment TOP: Neurologic Clinical
, Assessment and Diagnostic Procedures MSC: NC LEX:
Health Promotion and Maintenance
3. The nurse is caring for a patient with a head injury and observes a
rhythmic increase and decrease in the rate and depth of respiration
followed by brief periods of apnea. What should the nurse document
under breathing pattern?
a. Central neurogenic hyperventilation
b. Apneustic breathing
c. Ataxic respirations
d. Cheyne-Stokes respi rations
ANS: D
Cheyne-Stokes respirations have a rhythmic crescendo and decrescendo
of rate and depth of respiration, including brief periods of apnea. These
respirations are usuall y seen with bilateral deep cerebral lesions or
some cerebellar lesions. C entral neurogenic hyperventilations are very
deep, very rapid respirations with no apneic periods. They are usuall y
seen with lesions of the midbrain and upper pons. Apneustic breathing
includes clusters of irregular, gasping respirations separated by long
periods of apnea. They are usuall y seen in lesions of the lower pons or
upper medulla. Ataxic respirations are irregular, random patterns of
deep and shallow respirations with irregular apneic periods. They are
usuall y seen in lesions of the medulla.
PTS: 1 DIF: Cognitive Level: Appl ying OBJ: Nursing
Process Step: Diagnosis TOP: Neurologic Clinical
Assessment and Diagnostic Procedures MSC: NC LEX:
Health Promotion and Maintenance
