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?

Neurological status intact.

Glasgow Coma Scale (GCS) of 15.

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

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

Answer and Explanation

The Correct Answer is D

A) Neurological status intact: While the findings suggest that the client's neurological status is intact, this description does not specifically address the pupillary assessment.

B) Glasgow Coma Scale (GCS) of 15: The Glasgow Coma Scale evaluates a client's level of consciousness based on eye, verbal, and motor responses. While the findings may contribute to an overall assessment of neurological function, they specifically pertain to pupillary assessment.

C) Pupils equal, round, reacts to light, and accommodation (PERLA): This description includes accommodation, which is the ability of the pupils to constrict when focusing on a near object. The assessment provided in the scenario does not mention accommodation testing, so including it in the documentation would be inaccurate.

D) Pupils equal, round, reacts to light (PERRL): This notation accurately summarizes the findings of the pupillary assessment. It indicates that both pupils are equal in size, round in shape, and react briskly to light, which is a normal finding. This documentation is concise and specific to the pupillary examination without including additional findings not assessed in the scenario.

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Correct Answer is D

Explanation

A) Presents with a hacking nonproductive cough of 6 weeks duration:
This documentation accurately describes the client's symptom of a cough but does not capture the client's expressed concern about the possibility of lung cancer. It is important to document the client's specific concerns and fears.

B) Expresses concern of "lung cancer" symptoms for last 6 weeks:
While this option captures the client's concern about lung cancer, it does not specifically describe the client's symptom of a dry cough. Effective documentation should include both the client's expressed concerns and the associated symptoms.

C) An adult male presents with fears that he has "lung cancer":
This option captures the client's fear of having lung cancer but does not describe the specific symptom of a dry cough that the client is experiencing. Including the specific symptom in the documentation is important for comprehensive assessment and evaluation.

D) Describes having a "body wracking dry cough" of 6 weeks duration:
This option effectively documents both the client's specific symptom (dry cough) and the duration of the symptom (6 weeks), which aligns with the client's expressed concerns. It accurately reflects the client's statement and provides valuable information for the healthcare provider's assessment and management.

A. Normal mental status for age. B. Impaired memory. C. Impaired concentration. D. Impaired thinking.

Correct Answer is D

Explanation

A) Normal mental status for age: This response would suggest that the client's cognitive functions are appropriate for her age and educational background, which is not the case here. The response to the proverb "Glass Houses" indicates a lack of understanding or incorrect interpretation, which is not consistent with normal mental status.

B) Impaired memory: Impaired memory would typically manifest as difficulty recalling past events, recent information, or specific details. The client's response to the proverb does not indicate a memory problem but rather a difficulty in interpreting abstract concepts.

C) Impaired concentration: Impaired concentration would usually be indicated by the client's inability to focus on the conversation, becoming easily distracted, or having trouble maintaining attention. The client’s response to the proverb suggests more of a cognitive processing issue rather than an attention issue.

D) Impaired thinking: This is the most accurate conclusion. The client's response to the proverb "Glass Houses" ("It will break the windows") suggests difficulty with abstract thinking and interpreting common proverbs. Proverbs are often used to assess abstract thinking and reasoning abilities. A correct response would typically relate to the proverb's intended meaning about hypocrisy or not criticizing others when you have faults yourself, indicating that the client might have issues with abstract reasoning and impaired thinking.

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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?

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Correct Answer is D

Explanation

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

Correct Answer is D

Explanation

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