A 70year old client diagnosed with a hemorrhagic stroke was admitted 1 day ago. His

medical history includes hypertension, osteoarthritis, and type 2 diabetes. He has right sided

paralysis, garbled speech, and a weak cough reflex. This morning he is restless. Vital signs are Blood Pressure 160/80, pulse 110, respirations 24, oxygen saturation 90% Which of the following Interventions will the nurse take to avoid complications? Select all that apply

Select All that Apply)

Apply oxygen

Monitor blood pressure

Implement seizure precautions

Provide oral fluids

Turn the client twice each shift

Answer and Explanation

Correct Answer : A,B,C,F

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Correct Answer is C

Explanation

Febrile. This is incorrect because febrile seizures are associated with high fever and usually occur in children between 6 months and 5 years of age. They are typically generalized and brief, lasting less than 15 minutes.

Absence. This is incorrect because absence seizures are characterized by brief episodes of staring or loss of awareness, without any motor activity or change in level of consciousness.

Complex partial. This is correct because complex partial seizures involve impaired consciousness and automatisms, such as lip smacking, chewing, or fidgeting. They may also involve focal motor activity, such as twitching of one side of the face or body.

Clonictonic. This is incorrect because clonictonic seizures involve alternating muscle contraction and relaxation, resulting in jerking movements of the limbs and trunk. They are usually preceded by a loss of consciousness and followed by a period of confusion or sleepiness

A. asystole B. hypotension C. widening pulse pressure D. bradycardia and bounding pulse E. uneven breathing

Correct Answer is ["B","C","D","E"]

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is observed with unilateral twitching of facial muscles and repetitive tongue thrusting, with a decrease in level of consciousness. When the nurse reports her findings to the physician, what type of seizure will she indicate she observed?

Correct Answer is C

Explanation

A nurse is monitoring the vitals of a client who has a traumatic brain injury. Which of the following indicate that the client is in stage 3 of increased Intracranial pressure? Select all that apply (Select All that Apply.)

Correct Answer is ["B","C","D","E"]

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

A client arrives to the emergency department after a motor vehicle accident. The nurse records the following Glasgow Coma scores: E3, V2, M1. What is the best first action for the nurse to take.

A client arrived by EMS after a bar fight. He is disoriented with a Glasgow coma scale of 10. What additional finding indicates that he has suffered a basilar skull fracture?

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

A client newly diagnosed with multiple sclerosis is receiving education about newly prescribed medications from the nurse. Which of the following will be included in the client teaching?

A nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?