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, and accommodation (PERLA).

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

Neurological status intact.

Glasgow Coma Scale (GCS) of 15.

Answer and Explanation

The Correct Answer is B

A. The term PERLA (Pupils Equal, Round, React to Light and Accommodation) is often used, but the assessment described does not include the accommodation response, so it would not be accurate to document it as PERLA.
B. PERRL (Pupils Equal, Round, React to Light) is the correct notation, as it accurately reflects the findings described: pupils that are equal, round, and respond to light.
C. Documenting "Neurological status intact" is too vague and does not specifically address the pupil assessment.
D. The Glasgow Coma Scale (GCS) of 15 indicates a fully alert and oriented client but does not directly document the specific findings related to pupil assessment.

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Correct Answer is B

Explanation

A. A positive Homan's sign indicates potential deep vein thrombosis (DVT) but is not a common or reliable indicator for chronic swelling of the feet. Bilateral swelling is less likely related to DVT and more likely to be due to systemic issues.
B. 2+ pitting edema of the ankles bilaterally directly indicates chronic swelling. This finding supports the client's statement of persistent swelling, which is characteristic of fluid retention or systemic issues affecting both feet.
C. Capillary refill greater than 3 seconds may indicate poor peripheral circulation but does not directly assess or confirm chronic swelling of the feet.
D. Weak and thready pedal pulses suggest poor blood flow but are not directly related to the symptom of chronic swelling. They indicate possible circulatory issues rather than swelling alone.

Correct Answer is []

Explanation

Potential Condition:

Lobar pneumonia

Actions to Take:

Assess for prolonged expiration - This can help determine if there is an obstructive component affecting the airflow, which is common in pneumonia.
Inspect the chest for lag on the affected side - This can help identify reduced movement due to lung involvement or fluid in the lung area.

Parameters to Monitor:

Crackle - Crackles (rales) can indicate fluid in the alveoli, which is characteristic of pneumonia.
Cyanosis - Monitoring for cyanosis can help assess the severity of hypoxemia and overall respiratory function.

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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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Naxlex Comprehensive Predictor Exams

Which assessment finding supports the client statement, "My feet swell all the time?"

Correct Answer is B

Explanation

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

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