. 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 D

Explanation

A. Obtain a drug urine screen to verify the legitimacy of the client's stated history. This may be necessary but is not the initial approach for obtaining a health history.

B. Use the term illegal or illicit to describe street drugs. Using stigmatizing terms may make the client uncomfortable and less likely to disclose information.

C. Allow the client to decline answering social questions. The nurse should encourage open communication, but also respect the client's right to privacy.

D. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts. This is the correct approach. Specific questions about substances and quantities help obtain accurate information.

A. Tenderness. B. Crepitus. C. Thrill. D. Non-tender.

Correct Answer is D

Explanation

A. Tenderness. Tenderness indicates abnormality, such as inflammation, injury, or infection.
B. Crepitus. Crepitus, a crackling or popping sound, indicates abnormal air in subcutaneous tissues.
C. Thrill. A thrill, a palpable vibration, usually indicates turbulent blood flow and is abnormal.
D. Non-tender. This is the best choice as non-tenderness is a normal finding, indicating no inflammation, injury, or infection.

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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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