When performing an eye assessment using the PERRLA acronym, how do test for "A"?

Rationale:
A. A client who exercises daily is at low risk for pressure injuries. Regular movement promotes adequate circulation, reduces prolonged pressure on any one area, and maintains skin integrity. Activity is actually protective against pressure injury development.

B. An immobile client is at the greatest risk for pressure injuries. Pressure injuries develop when there is prolonged pressure over bony prominences (e.g., sacrum, heels, hips), which impairs blood flow and leads to tissue ischemia and breakdown. Immobility prevents repositioning, resulting in sustained pressure, decreased perfusion, and eventual tissue damage. Additional contributing factors often include moisture, friction, shear, and poor nutrition, but immobility is the primary and most significant risk factor.

C. A client with a mild headache has no direct risk for pressure injury unless other factors (like immobility) are present. A headache does not affect circulation, mobility, or skin integrity.

D. A client with seasonal allergies is not at increased risk for pressure injuries. Allergies may cause discomfort or respiratory symptoms but do not impair mobility or tissue perfusion in a way that contributes to pressure injury formation.

Rationale:

A. Client reports nipple discharge for the past week is subjective because the nurse is relying on the client’s personal report of experiencing discharge. The nurse cannot verify this symptom without direct observation at the time of the assessment, and the timing and description come from the client’s own account.

B. Axillary lymph node enlargement observed is objective data. The nurse can directly observe or palpate the lymph nodes, measure size, and document enlargement. It is a tangible sign that does not rely on the client’s perception.

C. Skin dimpling noted near the nipple is also objective data. The nurse observes the abnormal contour or indentation of the breast skin during examination, which can be verified visually and documented.

D. Client reports breast tenderness before menstruation is subjective because it is based on the client’s personal experience of discomfort or pain, which the nurse cannot measure. Pain and tenderness are classic examples of subjective findings because they rely on the client’s report.

E. A 2-cm firm mass palpated in the right breast is objective data. The nurse can physically feel, measure, and document the mass. This finding is tangible and reproducible on examination.