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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A) Hypogastric region:
The hypogastric region, also known as the suprapubic region, is located below the umbilical region and above the pubic area. Pain in the hypogastric region would be lower in the abdomen than described.

B) Epigastric region:
The epigastric region is located in the upper central part of the abdomen, just below the xiphoid process. Pain localized in the middle section of the abdomen below the xiphoid process is described as occurring in the epigastric region.

C) Umbilical region:
The umbilical region is located around the navel (belly button). Pain in this area would be centered around the umbilicus and not higher up near the xiphoid process.

D) Hypochondriac region:
The hypochondriac regions are located on either side of the epigastric region and below the ribcage. Pain in the hypochondriac region would be more lateral and not centrally located below the xiphoid process.

A. Give the client 8 ounces (236.5 mL) of water to drink. B. Evaluate the client for bladder distention. C. Instruct the client to attempt to urinate again. D. Send the sample for laboratory evaluation.

Correct Answer is B

Explanation

A. Give the client 8 ounces (236.5 mL) of water to drink:
While encouraging hydration is important for overall urinary function, providing water to drink may not immediately address the client's current situation of difficulty providing a urine sample. It's essential to first determine if bladder distention is contributing to the client's symptoms.

B. Evaluate the client for bladder distention:
Given the client's symptoms of lower abdominal discomfort and difficulty providing a urine sample despite feeling the urge to urinate, bladder distention should be assessed. Bladder distention could indicate urinary retention, which may require intervention to relieve the discomfort and prevent complications such as urinary tract infection or bladder rupture.

C. Instruct the client to attempt to urinate again:
While encouraging the client to attempt to urinate again may be appropriate, it's essential to first assess for bladder distention to determine if there is an underlying issue contributing to the client's difficulty in providing a urine sample.

D. Send the sample for laboratory evaluation:
Sending the urine sample for laboratory evaluation is important for diagnostic purposes, but in this case, it's more important to address the immediate concern of the client's difficulty in providing an adequate sample. Evaluating for bladder distention would help guide further assessment and management.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Naxlex Comprehensive Predictor Exams

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

Correct Answer is B

Explanation

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

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?

The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m2. Based on this BMI, what should the nurse deduce about this client's general health? Reference Range: Body Mass Index (BMI) [Normal 18.5 to 24.9 kg/m2]

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

While obtaining a client's health history related to smoking cigarettes, the nurse plans to determine the client's smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.