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. Blood urea nitrogen (BUN): Elevated BUN can indicate kidney problems, but it's not the primary test for melena (black, tarry stools) which suggests upper gastrointestinal bleeding.
B. Glucose: Glucose levels might be abnormal in some conditions that can cause bleeding, but it's not the most specific test for melena.
C. White blood cell count (WBC): WBC might be elevated in response to infection or inflammation, but it's not the most specific test for melena.
D. Hematocrit: Hematocrit measures the percentage of red blood cells in the blood. Melena can indicate significant blood loss, and monitoring hematocrit helps assess the severity of bleeding and potential need for blood transfusions.
Correct Answer is C
Explanation
A: Apply a pulse oximeter to the foot. Continuous monitoring of oxygen saturation can help detect hypoxemia early, which can be a concern in post-term infants due to potential respiratory distress or meconium aspiration. However, while important, this is a monitoring measure and not an immediate corrective action for potential metabolic or respiratory issues directly associated with post-term birth.
B: Draw arterial blood gases. Arterial blood gases (ABGs) provide critical information about the newborn's acid-base balance, oxygenation, and ventilation status. Post-term infants are at risk for hypoxia and acidosis, often due to placental insufficiency or meconium aspiration. However, obtaining ABGs can be invasive and might not be the first-line immediate action unless there are signs of severe distress.
C: Obtain a capillary blood glucose. Post-term infants are at increased risk for hypoglycaemia due to increased glucose utilization and possible depletion of glycogen stores. Hypoglycaemia can lead to serious complications if not promptly identified and managed. Therefore, checking blood glucose levels is a critical, non-invasive, and immediate step to ensure metabolic stability and prevent complications such as seizures and brain injury.
D: Provide blow-by oxygen. Blow-by oxygen is used to provide supplemental oxygen in a non-invasive manner and can help in cases of mild respiratory distress. Post-term infants can be at risk for respiratory issues, including meconium aspiration syndrome. However, this is usually applied when there is evidence of respiratory distress and not as a routine measure without specific indications.
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