What makes a focused assessment different from a comprehensive assessment?
Occurs only in the clinical area
Involves all body systems
Covers the body from head to toe
More in depth on specific issues
The Correct Answer is D
A) Occurs only in the clinical area: Focused assessments can be conducted in various settings, including outpatient clinics, home health visits, and emergency departments. Thus, this statement does not accurately define the difference.
B) Involves all body systems: A focused assessment is specifically targeted and does not involve an evaluation of all body systems. Instead, it concentrates on particular areas of concern, making this statement incorrect.
C) Covers the body from head to toe: This describes a comprehensive assessment rather than a focused one. A comprehensive assessment is thorough and covers the entire body, while a focused assessment zeroes in on specific issues or symptoms.
D) More in depth on specific issues: A focused assessment is designed to gather detailed information about particular health problems or concerns rather than providing a broad overview of the patient’s overall health. This targeted approach allows healthcare providers to identify and address specific needs effectively, making this the correct choice.
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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 A
Explanation
A) Increased muscle weakness: Guillain-Barré syndrome is characterized by the rapid onset of muscle weakness, which typically starts in the lower extremities and ascends. The nurse would expect to find varying degrees of muscle weakness as a hallmark symptom, which may progress to involve the upper limbs and respiratory muscles.
B) Pronounced muscle atrophy: While muscle weakness is a significant feature of Guillain-Barré syndrome, pronounced muscle atrophy is not typically seen immediately. Muscle atrophy may occur over time due to disuse but is not a direct initial finding upon assessment.
C) Diminished visual acuity: Visual acuity may not be directly affected in Guillain-Barré syndrome. While some patients may experience ocular symptoms, diminished visual acuity is not a primary feature of the syndrome and would not be expected as a common assessment finding.
D) Impaired cognitive reasoning: Guillain-Barré syndrome primarily affects the peripheral nervous system and does not usually impact cognitive function. Patients typically maintain full cognitive abilities, so the nurse should not anticipate findings