The nurse documents that the client's pupillary reaction is PERRLA. What is the "A" in this assessment describing about the client's eyes?
Changes in peripheral vision in response to light
Involuntary blinking in the presence of bright light
Pupillary dilation when looking at a near object
Pupillary constriction when looking at a near object
The Correct Answer is D
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is D
Explanation
A) Inflammation of the lamina of the involved vertebra: While inflammation can contribute to pain, it is not the primary cause in the context of a herniated disc. The pain associated with a herniated disc is typically related to nerve compression rather than inflammation of the lamina itself.
B) Shifting of two adjacent vertebrae out of alignment: This describes a different condition, such as spondylolisthesis. A herniated disc primarily involves the displacement of disc material, rather than a significant misalignment of the vertebrae.
C) Increased pressure of cerebral spinal fluid within the vertebral column: Increased cerebrospinal fluid pressure is not typically associated with herniated discs and does not directly cause the pain related to this condition.
D) Compression of the spinal cord by the extruding disc: This is the most accurate explanation for the patient's pain. A cervical herniated disc can protrude and compress nearby nerve roots or the spinal cord itself, leading to significant pain, weakness, and other neurological symptoms. This compression is the primary cause of pain in patients with this diagnosis.
Correct Answer is B
Explanation
A) To determine the location of the pain: While knowing the location of the pain can be relevant for overall assessment, this is not the main reason for reassessing pain after treatment. The focus is more on understanding the response to treatment rather than just identifying where the pain is.
B) To establish the effectiveness of medication: Reassessing pain after treatment is essential to evaluate how well the medication has alleviated the pain. This helps the nurse determine if the current pain management approach is effective or if modifications are necessary to improve the patient's comfort.
C) To make changes to the patient's pain goal: While understanding pain levels can inform care planning, the primary purpose of reassessing pain is to gauge treatment effectiveness rather than directly changing the pain management goals at that moment.
D) To measure the pain's duration: Measuring the duration of pain may be useful in a broader context of pain management, but it is not the immediate rationale for reassessing pain after treatment. The focus should be on the effectiveness of the intervention rather than just how long the pain lasts.