. 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 C

Explanation

A. Cool, pale skin below the knees. This suggests arterial insufficiency rather than venous insufficiency.

B. Deep, continuous pain in the calf muscles. This suggests deep vein thrombosis (DVT) rather than chronic venous insufficiency.

C. Decreased pain when legs are elevated. This is the best choice as elevation typically relieves symptoms of venous insufficiency by reducing venous pressure.

D. Painful symptoms alleviated by warmth. This is less specific to venous insufficiency and more indicative of muscle or joint issues.

A. Rigidity and firmness. B. Sharp, severe pain. C. Rebound tenderness. D. Audible thud without pain.

Correct Answer is B

Explanation

A. Rigidity and firmness. This is not typically expected; rigidity and firmness may indicate muscle spasm or guarding.

B. Sharp, severe pain. This is expected with pyelonephritis, as percussion over the inflamed kidney will elicit pain.

C. Rebound tenderness. Rebound tenderness is more indicative of peritoneal irritation rather than pyelonephritis.

D. Audible thud without pain. This is a normal finding; absence of pain does not align with the expected findings in pyelonephritis.

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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

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Explanation

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