A patient states, "I feel like the whole room is spinning around me, and it makes me feel nauseous sometimes." That term will the nurse use to document the patient's symptom?
Dizziness
Tinnitus
Vertigo
Otalgia
The Correct Answer is C
A) Dizziness: While the term "dizziness" can describe a range of sensations, it is more general and does not specifically capture the experience of the patient feeling that the room is spinning. Dizziness can include feelings of lightheadedness or imbalance, which are not the primary symptoms the patient is describing.
B) Tinnitus: Tinnitus refers to the perception of sound, such as ringing or buzzing, in the absence of an external source. This term does not relate to the patient's symptoms of spinning sensations and nausea, making it irrelevant in this context.
C) Vertigo: This term accurately describes the sensation of spinning or movement, often associated with inner ear disturbances. The patient's description aligns with vertigo, as it reflects the specific experience of feeling as though the environment is moving, which can indeed lead to nausea.
D) Otalgia: Otalgia refers to ear pain and is not applicable to the symptoms the patient describes. Since the patient is focusing on a spinning sensation and associated nausea, this term does not relate to the presenting issue.
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Correct Answer is D
Explanation
A) Changes in peripheral vision in response to light: While peripheral vision is important in a comprehensive eye assessment, it is not specifically evaluated through the PERRLA acronym. PERRLA focuses on how the pupils respond to light and accommodation, not on peripheral vision changes.
B) Involuntary blinking in the presence of bright light: Involuntary blinking is part of a reflex action known as the blink reflex, which helps protect the eyes from bright lights and foreign objects. However, this response is not what the "A" in PERRLA refers to, which is more specifically about pupillary reactions to focus.
C) Pupillary dilation when looking at a near object: When focusing on a near object, the pupils actually constrict rather than dilate. This process, known as accommodation, is important for clear vision at close distances but does not pertain to the dilation of pupils.
D) Pupillary constriction when looking at a near object: The "A" in PERRLA stands for accommodation, which specifically refers to the pupils constricting when a person looks at a nearby object. This reaction helps the eyes focus properly and is a normal finding in a healthy neurological assessment. Thus, option D accurately describes the "A" in the PERRLA assessment.
Correct Answer is ["B","C","D","E"]
Explanation
A) Range of motion: While assessing range of motion can provide information about joint function, it is not a specific component of a peripheral vascular assessment. This assessment primarily focuses on circulation and vascular integrity rather than mobility.
B) Color: Assessing the color of the upper extremities is essential in a peripheral vascular assessment. Changes in color can indicate issues such as poor circulation, hypoxia, or vascular disease, making it a critical observation.
C) Fine motor assessment by having the client touch each finger to thumb: This assessment evaluates both coordination and dexterity, which can indicate adequate blood flow to the fingers and upper extremities. It helps to assess the functional capacity of the hands in relation to vascular health.
D) Pain assessment: Evaluating for pain in the upper extremities is important, as pain can be a sign of vascular problems, including conditions like peripheral artery disease. It provides insight into the presence of ischemia or other vascular issues.
E) Pulses intact: Assessing the pulses in the upper extremities is a key component of a peripheral vascular assessment. Palpating the radial and brachial pulses helps determine blood flow and vascular function in the arms.