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?
Pupils equal, round, reacts to light (PERRL)
Pupils equal, round, reacts to light, and accommodation (PERLA)
Neurological status intact.
Glasgow Coma Scale (GCS) of 15.
The Correct Answer is A
A. Pupils equal, round, reacts to light (PERRL) This notation accurately reflects the observed findings.
B. Pupils equal, round, reacts to light, and accommodation (PERLA) While it includes accommodation, there was no specific assessment of accommodation mentioned.
C. Neurological status intact. This is too vague and does not provide specific details about the pupils.
D. Glasgow Coma Scale (GCS) of 15. The GCS score indicates overall neurological function, not specific pupil findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Deep, continuous pain in the calf muscles. This symptom is more indicative of deep vein thrombosis (DVT) rather than venous insufficiency.
B. Painful symptoms alleviated by warmth. This symptom is not typically associated with venous insufficiency; it may be seen in conditions like arthritis.
C. Cool, pale skin below the knees. This finding is more suggestive of arterial insufficiency rather than venous insufficiency.
D. Decreased pain when legs are elevated. Venous insufficiency is characterized by impaired blood flow in the veins, leading to symptoms such as leg aching, tiredness, swelling, and skin changes like leathery appearance. Elevating the legs can help alleviate symptoms of venous insufficiency by reducing venous pressure and improving blood flow back to the heart. Therefore, a subjective finding indicating decreased pain when the legs are elevated suggests venous insufficiency.
Correct Answer is C
Explanation
A. Compress the tissue around the ankles: Compressing the tissue around the ankles can assess for edema but does not provide direct information about arterial circulation.
B. Observe plantar flexion and dorsiflexion: Observing plantar flexion and dorsiflexion assesses motor function and muscle strength but does not directly assess arterial circulation.
C. Palpate the volume of the pedal pulses: Palpating pedal pulses is a direct method to assess arterial blood flow to the lower extremities. It provides information about the strength and quality of arterial circulation.
D. Stroke the soles and note toe movement: Stroking the soles and noting toe movement is the Babinski reflex test, which assesses neurological function, not arterial circulation.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
