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).

Neurological status intact.

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

Glasgow Coma Scale (GCS) of 15.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Pupils equal, round, and reactive to light (PERRL) 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.
Choice B rationale
Documenting “neurological status intact” is too vague and does not specifically describe the pupillary assessment findings.
Choice C rationale
Pupils equal, round, reactive to light, and accommodation (PERLA) includes an additional assessment of accommodation, which was not mentioned in the scenario.
Choice D rationale
The Glasgow Coma Scale (GCS) of 15 is a general assessment of consciousness and does not specifically describe the pupillary findings.

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Correct Answer is B

Explanation

Choice A rationale
Diabetes mellitus can lead to various complications affecting the nails, such as yellowing or thickening due to poor circulation and infections, but it is not typically associated with brittle, concave (spoon-shaped) nails.
Choice B rationale
Iron deficiency anemia is often associated with brittle, spoon-shaped (concave) nails, known as koilonychia. This condition affects the oxygen-carrying capacity of the blood, leading to changes in the nail beds.
Choice C rationale
Coronary heart disease can lead to changes in the nails due to poor circulation, but it is not commonly associated with brittle, concave nails. Other nail changes might include clubbing or cyanosis.
Choice D rationale
Recent candida infection can affect the nails, causing them to become discolored, thickened, or separated from the nail bed, but it does not typically cause the nails to become brittle and concave.

A. Detailed Questions about a symptom. B. Open-ended Questioning. C. Closed-ended Questions. D. Leading Questions.

Correct Answer is B

Explanation

Choice A rationale
Detailed questions about a symptom may be useful but can limit the client’s ability to provide a comprehensive description of the sputum.
Choice B rationale
Open-ended questioning allows the client to describe the sputum in their own words, providing more detailed and accurate information.
Choice C rationale
Closed-ended questions may limit the client’s responses and fail to capture important details about the sputum.
Choice D rationale
Leading questions can bias the client’s responses and may not provide accurate information about the sputum.

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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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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?