A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye) response by:
a. introducing ice water into the external auditory canal.
b. touching the cornea with a wisp of cotton.
c. turning the client’s head suddenly while holding the eyelids open.
d. shining a bright light into the pupil.
Answer C.
To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client’s head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client’s eyes deviate to the side of ice water introduction. The nurse touches the client’s cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client’s pupil helps evaluate brain stem and cranial nerve III functions; normally, the pupil responds by constricting.
a. introducing ice water into the external auditory canal.
b. touching the cornea with a wisp of cotton.
c. turning the client’s head suddenly while holding the eyelids open.
d. shining a bright light into the pupil.
Answer C.
To elicit the oculocephalic response, which detects cranial nerve compression, the nurse turns the client’s head suddenly while holding the eyelids open. Normally, the eyes move from side to side when the head is turned; in an abnormal response, the eyes remain fixed. The nurse introduces ice water into the external auditory canal when testing the oculovestibular response; normally, the client’s eyes deviate to the side of ice water introduction. The nurse touches the client’s cornea with a wisp of cotton to elicit the corneal reflex response, which reveals brain stem function; blinking is the normal response. Shining a bright light into the client’s pupil helps evaluate brain stem and cranial nerve III functions; normally, the pupil responds by constricting.