The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?
Palpebral angle rigid, right and left angles
Patient's eyes round, regular, lively, active
Pupils equal, round, and reactive to light and accommodation
Pupils equilateral, regular, round, little accommodation
The Correct Answer is C
A. Palpebral angle rigid, right and left angles is not a part of the PERRLA assessment. The term refers to the space between the eyelids, which is not assessed with the PERRLA acronym.
B. Patient's eyes round, regular, lively, active is a description of the general appearance of the eyes but does not correspond to the PERRLA acronym, which specifically addresses the pupils' response to light and accommodation.
C. PERRLA stands for Pupils Equal, Round, and Reactive to Light and Accommodation. This means the pupils should be equal in size, round in shape, react to light (constricting when exposed to light), and accommodate (adjust) when focusing on near or far objects. This is a standard neurological assessment used to evaluate the functioning of the eyes and the nervous system.
D. Pupils equilateral, regular, round, little accommodation does not accurately describe PERRLA. The correct term is "accommodation," which refers to the pupils' ability to adjust when focusing on near or far objects, not "little accommodation."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Unstable blood pressure can occur with damage to the hypothalamus or pituitary, but it is more commonly associated with other neurological conditions. While blood pressure may fluctuate, it is not the most direct result of pituitary or hypothalamic damage.
B. Diabetes insipidus is the correct answer. The pituitary gland secretes antidiuretic hormone (ADH), which helps regulate water balance. Damage to the pituitary or hypothalamus can lead to a deficiency of ADH, causing diabetes insipidus, which is characterized by excessive thirst and urination.
C. Diabetes mellitus is a condition related to insulin production and blood sugar regulation, typically caused by pancreatic issues, not damage to the pituitary or hypothalamus.
D. Altered respiratory rate can occur with brain injury, but it is more commonly associated with damage to the brainstem rather than the hypothalamus or pituitary.
Correct Answer is B
Explanation
A. The ECG finding of an irregularly irregular heart rate without P waves is characteristic of atrial fibrillation, which is expected in this client. This finding is not the priority in this situation.
B. Slurred speech is a potential sign of a stroke, which is a serious complication of atrial fibrillation due to the increased risk of thromboembolic events (e.g., stroke). This is the priority finding because it requires immediate intervention to assess and manage a possible stroke.
C. An aPTT of 70 seconds is slightly elevated, but it is within the therapeutic range for heparin therapy (usually 1.5 to 2.5 times the normal value). It does not warrant immediate action.
D. Cloudy and odorous urine could indicate a urinary tract infection or other issue, but it is not immediately life-threatening compared to the potential for a stroke in this client.
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