The nurse documents that the client's pupillary reaction is PERRLA. What is the "A" in this assessment describing about the client's eyes?

Changes in peripheral vision in response to light

Involuntary blinking in the presence of bright light

Pupillary dilation when looking at a near object

Pupillary constriction when looking at a near object

Answer and Explanation

The Correct Answer is D

A) Changes in peripheral vision in response to light: While peripheral vision is important in a comprehensive eye assessment, it is not specifically evaluated through the PERRLA acronym. PERRLA focuses on how the pupils respond to light and accommodation, not on peripheral vision changes.

B) Involuntary blinking in the presence of bright light: Involuntary blinking is part of a reflex action known as the blink reflex, which helps protect the eyes from bright lights and foreign objects. However, this response is not what the "A" in PERRLA refers to, which is more specifically about pupillary reactions to focus.

C) Pupillary dilation when looking at a near object: When focusing on a near object, the pupils actually constrict rather than dilate. This process, known as accommodation, is important for clear vision at close distances but does not pertain to the dilation of pupils.

D) Pupillary constriction when looking at a near object: The "A" in PERRLA stands for accommodation, which specifically refers to the pupils constricting when a person looks at a nearby object. This reaction helps the eyes focus properly and is a normal finding in a healthy neurological assessment. Thus, option D accurately describes the "A" in the PERRLA assessment.

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Correct Answer is D

Explanation

A) "Have you ever had any surgeries?": While this question is important, it is more specific and may not provide the comprehensive context needed to guide the interview. It could lead to a narrow focus on past surgical history without addressing the client’s current health status or concerns.

B) "Tell me about any medical problems that you have had.": This question is useful but lacks the immediate relevance to the client's current situation. It may prompt the client to recount past issues rather than focusing on their current health needs and reasons for seeking care.

C) "Tell me about any medications you are currently taking.": This is an essential aspect of health history, but like the previous options, it doesn't address the client’s immediate concerns or symptoms that may guide the rest of the interview.

D) "Tell me why you are seeking care today.": This question is the most effective starting point as it directly addresses the client’s current health issue or concern. Understanding the reason for seeking care helps the nurse prioritize topics, gather relevant information, and tailor the rest of the health history interview to the client’s specific needs, making it a crucial guide for further questioning.

A. Symmetry B. Hard nodules C. Skin texture D. Tenderness

Correct Answer is A

Explanation

A) Symmetry: During a breast inspection, the nurse should assess for symmetry between the two breasts. It is normal for there to be some slight differences, but significant asymmetry can indicate underlying issues that may need further evaluation.

B) Hard nodules: While the presence of hard nodules would be a significant finding, this would typically be assessed through palpation rather than inspection. The initial visual assessment focuses on appearance, shape, and symmetry.

C) Skin texture: Skin texture may be observed during inspection, but it is not a primary finding that stands out as a key assessment element. It can be noted as part of a comprehensive evaluation but is not the main focus.

D) Tenderness: Tenderness is a subjective assessment that is evaluated through palpation and client reporting, rather than through inspection. The nurse cannot document tenderness solely based on visual assessment.

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The nurse documents that the client's pupillary reaction is PERRLA. What is the "A" in this assessment describing about the client's eyes?

Nursing Test Bank

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