. 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?

Glasgow Coma Scale (GCS) of 15.

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

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

Neurological status intact.

Answer and Explanation

The Correct Answer is C

A. Glasgow Coma Scale (GCS) of 15. The GCS is a measure of consciousness and not specific to pupil assessment. It assesses eye opening, verbal response, and motor response.

B. Pupils equal, round, reacts to light, and accommodation (PERLA). This notation is incorrect because the nurse only assessed for light reaction, not accommodation.

C. Pupils equal, round, reacts to light (PERRL). This is the correct documentation based on the observed findings.

D. Neurological status intact. This is a general statement and does not specifically document the pupil findings.

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Correct Answer is ["A","C","E"]

Explanation

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants. Using a warmed stethoscope bell helps ensure that the stethoscope is at a comfortable temperature for the patient. However, the diaphragm of the stethoscope is typically used for bowel sounds, not the bell. Placing the stethoscope lightly over all four quadrants ensures that you are listening to all areas of the abdomen.

B. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent. This is not necessary for most clinical situations. If bowel sounds are not heard within 1-2 minutes, you may document them as absent. Listening for a full 5 minutes is typically reserved for more specific assessments, such as suspected bowel obstruction.

C. Turn the suction off while auscultating. Suction from a nasogastric tube can cause noise that may interfere with the assessment of bowel sounds. Turning off the suction ensures that you can hear the actual bowel sounds without interference.

D. Palpate the abdomen before auscultating. Palpation should be done after auscultation to avoid stimulating bowel sounds, which can affect the accuracy of your assessment. Palpating before auscultation may alter the natural bowel sounds and provide misleading results.

E. Place the stethoscope in the ears with the earpieces pointing towards the ears. The earpieces of the stethoscope should point towards the ears to ensure proper acoustics and clear sound transmission.

A. Color characteristics of each stool. B. Number of blood clots expelled with each stool. C. Unique odor noted with gastrointestinal bleeding. D. Evidence of internal hemorrhoids.

Correct Answer is A

Explanation

A. Color characteristics of each stool. This is the best choice as it provides important information about the possible source and nature of the bleeding (e.g., bright red indicates lower GI bleeding, while dark tarry stools indicate upper GI bleeding).
B. Number of blood clots expelled with each stool. While this could be relevant, it is less commonly noted and might be more subjective unless quantified consistently.
C. Unique odor noted with gastrointestinal bleeding. The odor can sometimes indicate the presence of blood, but it is not a primary characteristic to document compared to stool color and consistency.
D. Evidence of internal hemorrhoids. Internal hemorrhoids might be a source of bleeding, but this requires confirmation through a physical examination, typically by a healthcare provider.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

When evaluating a client's rectal bleeding, which findings should the nurse document?

Correct Answer is A

Explanation

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