Page 398 - Saunders Comprehensive Review For NCLEX-RN

FIG. 12-1 Checking extraocular muscles in the 6 cardinal positions. This indicates the
functioning of cranial nerves III, IV, and VI.

Box 12-5

Assessing and Documenting Pupillary Responses
Pupillary Light Reflex

1. Darken the room (to dilate the client’s pupils) and ask the client to look
forward.
2. Test each eye.
3. Advance a light in from the side to note constriction of the same-side pupil
(direct light reflex) and simultaneous constriction of the other pupil
(consensual light reflex).

Accommodation

1. Ask the client to focus on a distant object (dilates the pupil).
2. Ask the client to shift gaze to a near object held about 3 inches (7.5 cm) from
the nose.
3. Normal response includes pupillary constriction and convergence of the axes
of the eyes.

Documenting Normal Findings: PERRLA

P = pupils
E = equal
R = round
RL = reactive to light (direct and consensual)
A = reactive to accommodation

Box 12-6

Vestibular Assessment

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