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

Ask the patient to follow your finger through the six cardinal fields of gaze.

Move your finger slowly toward the patient's nose and observe the pupils constrict and the eyes converge.

Shine a penlight into each eye and observe constriction of both pupils

Ask the patient to focus on a distant object and then read a near vision card.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Asking the patient to follow your finger through the six cardinal fields of gaze assesses extraocular muscle function and eye movement, not the "A" in PERRLA. This test evaluates cranial nerves III, IV, and VI, but it does not measure accommodation.

B. Moving your finger slowly toward the patient's nose and observing the pupils constrict and the eyes converge tests Accommodation, which is what the "A" in PERRLA represents. Accommodation involves the pupils adjusting for near vision (constricting) and convergence of the eyes, ensuring that the eyes can focus properly on close objects. This is the correct method for testing "A."

C. Shining a penlight into each eye and observing constriction of both pupils tests Pupillary Light Reflex, which corresponds to the "P" and "R" (Pupils Equal, Round, Reactive to Light) in PERRLA. This does not assess accommodation.

D. Asking the patient to focus on a distant object and then read a near vision card evaluates near and distance vision acuity, but it does not specifically test the pupillary constriction and convergence associated with accommodation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is ["D","E"]

Explanation

Rationale:

A. Lymph nodes that are freely moveable under the skin are typically normal. Mobility indicates that the node is not infiltrated by fibrotic tissue or malignant cells. Moveable nodes may shift slightly during palpation and are usually soft or rubbery.

B. Smooth lymph nodes are generally normal. Irregular, nodular, or spiculated nodes are more concerning for pathology. Smoothness alone does not indicate abnormality.

C. Non-tender lymph nodes are often normal, particularly if they are small and soft. Tenderness is usually associated with acute infections, such as localized cellulitis or mastitis. Therefore, non-tender nodes in isolation are not considered abnormal.

D. Hard lymph nodes are abnormal. Hardness suggests that the node may be infiltrated with malignant cells or fibrotic tissue, which can occur in breast cancer metastasis or chronic infections. Hard nodes are less compressible and may be associated with an irregular surface.

E. Fixed, immobile lymph nodes are also abnormal. Normal nodes are freely movable; when nodes are adherent to surrounding tissues, it can indicate malignancy, fibrosis, or metastatic spread. Fixed nodes do not shift easily with palpation and require prompt medical evaluation.

A. Bradycardia B. Decreased level of consciousness C. Shivering D. Hypotension

Correct Answer is C

Explanation

Rationale:

A. Bradycardia is typically a later sign of moderate to severe hypothermia, as the body’s core temperature drops significantly. Early hypothermia usually triggers compensatory mechanisms rather than slowing the heart rate.

B. Altered mental status occurs later in hypothermia when core body temperature falls substantially. Early stages are usually accompanied by alertness, as the body attempts to generate heat.

C. Shivering is the primary early physiological response to cold exposure. It is the body’s mechanism to generate heat through involuntary muscle activity and typically occurs when core body temperature begins to drop slightly below normal (mild hypothermia, 35–36°C or 95–96.8°F). Shivering is an important warning sign that the body is losing heat and compensating to maintain homeostasis.

D. Hypotension is a later manifestation of hypothermia due to cardiovascular depression and vasoconstriction failure. Early hypothermia usually presents with peripheral vasoconstriction, not low blood pressure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing lymph nodes associated with the breast, which findings should the nurse consider abnormal? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

During an assessment of a client exposed to cold temperatures, which finding would the nurse recognize as an early manifestation of hypothermia?

Correct Answer is C

Explanation

During a skin assessment of an adult client, which finding is considered expected?

A nurse is assessing an infant during a routine health examination. The nurse notes that the infant's anterior fontanel is sunken. How should the nurse interpret this finding?

A nurse is teaching a class about the function of cells in the epidermis. The nurse should include that which of the following cells determine skin color?

A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?

A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)

The nurse is conducting an interview. Which of these statements is true regarding open-ended questions? (Select All that Apply.)

A nurse is caring for a client who reports a decrease in central vision. The nurse should identify that this is a manifestation of which of the following visual impairments?

A nurse is assessing a client with a suspected thyroid disorder. Which assessment finding would the nurse most strongly associate with hyperthyroidism?