Nokea
The examiner shines a light in the patient's eyes and notes that the pupils are round and constrict from 4 to 2 mm bilaterally. Next, the examiner asks the patient to focus on a far object, then on the examiner's finger as it is brought from 3 feet distance to 5 inches distance. The pupils constrict bilaterally and the eyes turn inward. Which of the ff. would be the correct documentation of these findings?
- A. Pupils 2 mm
- B. PERRLA
- C. Pupils constricted
- D. Pupils normal
Correct Answer: B
Rationale: PERRLA stands for Pupils Equal Round Reactive to Light and Accommodation. This acronym is used to document the findings seen during a neurological examination of the pupils.
You may also like to solve these questions
A patient complains of tingling in his fingers. He has positive Trousseau's and Chvostek's signs. He says that he feels depressed. Choose the most likely serum calcium (Ca ) value for this patient:
- A. 11mg/dl
- B. 7mg/dl
- C. 9mg/dl
- D. 5mg/dl
Correct Answer: A
Rationale: The patient's symptoms of tingling in the fingers, positive Trousseau's and Chvostek's signs, and feeling depressed are suggestive of hypocalcemia, which is commonly associated with low serum calcium levels. In this case, the most likely serum calcium value would be below the normal range, which is around 8.5-10.5 mg/dl. Among the given choices, an extremely low calcium value of 5mg/dl (Choice D) would be more consistent with severe hypocalcemia presenting with tetany and other neuromuscular symptoms rather than depression and mild symptoms. On the other hand, a high calcium level of 11mg/dl (Choice A) would indicate hypercalcemia, which can lead to neuropsychiatric symptoms like depression, as seen in this patient's presentation. Therefore, Choice A (11mg/dl) is the most likely serum calcium value for
The age by which the child can pull to stand, starting to pincer grasp, and plays pat-a-cake is
- A. 6 mo
- B. 7 mo
- C. 8 mo
- D. 9 mo
Correct Answer: D
Rationale: These milestones are typically achieved around 9 months of age.
When caring for Mr. Reyes, the nurse should assess for
- A. Decreased carotid pulses
- B. Altered level of consciousness
- C. Bleeding from oral cavity
- D. Absence of deep tendon-reflexes
Correct Answer: B
Rationale: When caring for Mr. Reyes, the nurse should assess for an altered level of consciousness as it is a crucial indicator of his overall neurological status. Changes in consciousness can signify multiple underlying issues such as neurological, metabolic, or circulatory problems. It is important for the nurse to monitor Mr. Reyes closely for any signs of confusion, disorientation, agitation, drowsiness, or changes in behavior that could indicate a decline in his neurological function. Assessing and addressing alterations in consciousness promptly is essential for providing appropriate care and preventing further complications.
Total parenteral nutrition (TPN) is ordered for an adult client. Which nutrient is not likely to be in the solution?
- A. dextrose
- B. electrolytes
- C. trace minerals
- D. amino acids
Correct Answer: C
Rationale: Total parenteral nutrition (TPN) is a method of providing nutrition intravenously to individuals who are unable to obtain adequate nutrition through oral or enteral routes. The components of a TPN solution typically include dextrose (a source of carbohydrates for energy), amino acids (building blocks of proteins), electrolytes (such as sodium, potassium, and magnesium to maintain proper balance), vitamins, and trace elements (such as zinc and selenium). Trace minerals are essential for various metabolic functions in the body, and their inclusion in TPN solutions is crucial to prevent deficiencies. Therefore, trace minerals are likely to be present in TPN solutions, making them an essential component, unlike the other options provided in the question.
An adult has been treated for pulmonary tuberculosis and is being discharged home with his wife and two young children. His wife asks how TB is passed from one person to another so she can prevent anyone from catching it. How should the nurse respond?
- A. You should wear gloves when handling his linen and bedding
- B. You should keep the windows and doors closed so as not to spread the droplets
- C. He must be careful to cough into a handkerchief that is washed in hot water or discarded
- D. Make sure to boil all water before drinking or using it
Correct Answer: C
Rationale: Tuberculosis is primarily spread through the air when an infected person coughs, sneezes, speaks, or sings, releasing bacteria-containing droplets into the air. Therefore, it is important for the individual with TB to cover their mouth and nose when coughing or sneezing to prevent the spread of the bacteria. By coughing into a disposable tissue or a handkerchief that can be washed in hot water, the risk of spreading the infection to others is significantly reduced. This measure helps minimize the transmission of the disease within the household and community.