To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

Observe pupil size when focusing on a near object and then a far object.

Determine if dilation of the pupils occurs when the room is darkened.

Note the speed of pupil constriction when a penlight is shined into the eye.

Compare the shape of each of the pupils bilaterally with normal room light.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Observing pupil size when focusing on a near object and then a far object assesses the accommodation reflex. This reflex involves the pupils constricting when focusing on a near object and dilating when focusing on a far object. This response is mediated by the parasympathetic nervous system and is a normal physiological reaction to changes in focal distance.
Choice B rationale
Determining if dilation of the pupils occurs when the room is darkened assesses the pupillary light reflex, not accommodation. The pupillary light reflex involves the pupils dilating in low light conditions to allow more light to enter the eye, which is controlled by the sympathetic nervous system.
Choice C rationale
Noting the speed of pupil constriction when a penlight is shined into the eye assesses the direct and consensual light reflexes. This test evaluates the function of the optic and oculomotor nerves and is not related to the accommodation reflex.
Choice D rationale
Comparing the shape of each of the pupils bilaterally with normal room light assesses for anisocoria or differences in pupil size, which can indicate neurological issues. This assessment does not evaluate the accommodation reflex.

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Correct Answer is A

Explanation

Choice A rationale
Describing the client’s exact words, “body-wracking dry cough” of 6 weeks duration, provides a clear and specific account of the client’s symptoms and concerns.
Choice B rationale
Expressing concern of “lung cancer” symptoms for the last 6 weeks is less specific and does not accurately capture the client’s primary symptom, which is the dry cough.
Choice C rationale
Presenting with a hacking nonproductive cough of 6 weeks duration is a clinical interpretation and does not use the client’s own words, which is important for accurate documentation.
Choice D rationale
An adult male presents with fears that he has “lung cancer” is a subjective interpretation and does not accurately describe the client’s primary symptom.

A. Pupils equal, round, reacts to light (PERRL). B. Neurological status intact. C. Pupils equal, round, reacts to light, and accommodation (PERLA). D. Glasgow Coma Scale (GCS) of 15.

Correct Answer is A

Explanation

Choice A rationale
Pupils equal, round, and reactive to light (PERRL) accurately summarizes the findings of the pupillary assessment. It indicates that both pupils are equal in size, round in shape, and react briskly to light, which is a normal finding.
Choice B rationale
Documenting “neurological status intact” is too vague and does not specifically describe the pupillary assessment findings.
Choice C rationale
Pupils equal, round, reactive to light, and accommodation (PERLA) includes an additional assessment of accommodation, which was not mentioned in the scenario.
Choice D rationale
The Glasgow Coma Scale (GCS) of 15 is a general assessment of consciousness and does not specifically describe the pupillary findings.

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To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

When performing a neurologic assessment on an alert client, the nurse observes that the client’s pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

Correct Answer is A

Explanation

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