. When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

Glasgow Coma Scale (GCS) of 15.

Pupils equal, round, reacts to light, and accommodation (PERLA).

Pupils equal, round, reacts to light (PERRL).

Neurological status intact.

Answer and Explanation

The Correct Answer is C

A. Glasgow Coma Scale (GCS) of 15. The GCS is a measure of consciousness and not specific to pupil assessment. It assesses eye opening, verbal response, and motor response.

B. Pupils equal, round, reacts to light, and accommodation (PERLA). This notation is incorrect because the nurse only assessed for light reaction, not accommodation.

C. Pupils equal, round, reacts to light (PERRL). This is the correct documentation based on the observed findings.

D. Neurological status intact. This is a general statement and does not specifically document the pupil findings.

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Correct Answer is B

Explanation

A. Recent over-the-counter infection cures. This is less immediately relevant unless directly related to lymph node changes.

B. Nontender, firm lymph nodes. This is the correct choice. Nontender, firm lymph nodes can indicate a more serious underlying condition such as malignancy or chronic infection and require further investigation.

C. Number of indoor cats at home. This might be relevant if there is a concern for cat scratch disease, but it is less critical than the nature of the lymph nodes.

D. Amount of daily caffeine consumption. This is not related to the palpation of lymph nodes and is not immediately relevant to the findings.

A. Begin to orient the client to her surroundings in the hospital room. B. Stand directly in front of the client and ask about any hearing loss. C. Obtain a tuning fork to complete Rinne and Weber tuning fork tests. D. Perform a mental status exam to assess the client's thought processes.

Correct Answer is B

Explanation

A. Begin to orient the client to her surroundings in the hospital room. Orienting the client is important but does not address the immediate issue of possible hearing loss, which might be causing the client's behavior.

B. Stand directly in front of the client and ask about any hearing loss. This is the best choice because it addresses the possible reason for the client's behavior directly. Standing in front of the client helps ensure she can see and hear the nurse clearly.

C. Obtain a tuning fork to complete Rinne and Weber tuning fork tests. These tests are useful for diagnosing hearing loss but are not the first step. Initial assessment should involve direct communication to identify the issue.

D. Perform a mental status exam to assess the client's thought processes. While assessing mental status is important, it does not address the immediate observation that the client may have hearing loss.

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. When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

Nursing Test Bank

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