Question

A nurse is assisting the health care provider in performing a caloric test on a client. Following instillation of cool water into the ear, the nurse notes the presence of nystagmus. The nurse should document the findings of this test as:

A. Normal response.
B. Abnormal response.
C. Positive Dix-Hallpike test.
D. Negative Barany test.

Answer 1

The nurse should document the findings of this caloric test as abnormal response because nystagmus is present, indicating dysfunction in the vestibular system.

Step-by-step explanation:

The nurse should document the findings of this test as abnormal response. Nystagmus is an involuntary eye movement that can occur in response to certain stimuli, such as the instillation of cool water into the ear. It is considered abnormal because it indicates dysfunction in the vestibular system, which is responsible for maintaining balance and spatial orientation. In a caloric test, the presence of nystagmus suggests an abnormal response and further evaluation may be needed to determine the underlying cause.