The nurse performs a visual assessment on a patient and documents the findings using the acronym PERRLA. Which assessment finding does PERRLA indicate?
Palpebral angle rigid, right and left angles
Patient's eyes round, regular, lively, active
Pupils equal, round, and reactive to light and accommodation
Pupils equilateral, regular, round, little accommodation
The Correct Answer is C
A. Palpebral angle rigid, right and left angles is not a part of the PERRLA assessment. The term refers to the space between the eyelids, which is not assessed with the PERRLA acronym.
B. Patient's eyes round, regular, lively, active is a description of the general appearance of the eyes but does not correspond to the PERRLA acronym, which specifically addresses the pupils' response to light and accommodation.
C. PERRLA stands for Pupils Equal, Round, and Reactive to Light and Accommodation. This means the pupils should be equal in size, round in shape, react to light (constricting when exposed to light), and accommodate (adjust) when focusing on near or far objects. This is a standard neurological assessment used to evaluate the functioning of the eyes and the nervous system.
D. Pupils equilateral, regular, round, little accommodation does not accurately describe PERRLA. The correct term is "accommodation," which refers to the pupils' ability to adjust when focusing on near or far objects, not "little accommodation."
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While chemotherapy does have side effects, this is not the primary reason for its limited use in treating brain tumors. Side effects are a consideration but not the main obstacle.
B. The blood-brain barrier is a selective permeability barrier that limits the ability of many chemotherapy drugs to pass from the bloodstream into the brain tissue. This makes it difficult for chemotherapy to effectively treat brain tumors.
C. Brain tumors can metastasize and spread to other parts of the body, so chemotherapy may still be needed, especially in cases of malignant tumors.
D. Chemotherapy is commonly used to treat cancer, including brain tumors, but the blood-brain barrier poses a significant challenge in its effectiveness.
Correct Answer is B
Explanation
A. A blood pressure cuff is not directly needed to assess neurological status. While blood pressure is important to monitor in neurological assessments, it is not the primary tool used for assessing neurological function.
B. A pen light is essential for assessing pupil reaction, which is a key part of a neurological exam. The nurse can use the pen light to check for pupil dilation, constriction, and reaction to light, which are important indicators of brain function.
C. A thermometer is useful for measuring body temperature but is not a primary tool for assessing neurological status. Although fever can be a sign of infection affecting the brain, it is not part of the basic neurological exam.
D. A stethoscope is useful for listening to heart and lung sounds, but it is not typically used for assessing neurological function. The pen light is the more appropriate tool for this purpose.
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