Hesi rn health assessment proctored exam
. 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?
Explanation & Rationale
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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