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 C

Explanation

Choice A rationale
Restricting activity to bed rest is important but not the most immediate intervention for a client with a high fever and pain during deep palpation.
Choice B rationale
Monitoring urinary output is important but not the most immediate intervention in this scenario.
Choice C rationale
Initiating NPO (nothing by mouth) status is crucial to prepare the client for potential surgical intervention, especially if the pain suggests an acute abdominal condition.
Choice D rationale
Obtaining an electrocardiogram is important but not the most immediate intervention for a client with abdominal pain and high fever.

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

During an abdominal assessment, a client with a temperature of 103°F (39.4°C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Correct Answer is C

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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