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)

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 caring for a client who had a rightsided stroke and is exhibiting homonymous hemlanopsia when eating. Which of the following actions should the nurse take?

A client with multiple sclerosis has been prescribed interferon B. Which of the following statements indicates the client understands the teaching about this medication.

After explaining the procedure for an electroencephalograph, which of the following statements by the client indicates teaching was not effective?

An 84year old client is brought to the emergency department with reports that his mental status has slowly been declining. He fell 2 weeks ago but did not seek medical attention. Based on this information, what does the nurse suspect the client's diagnosis will be?

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 in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?

Which of the following clients is most at risk for traumatic brain injury?

A nurse is caring for a client who has rightsided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

After performing a neurological assessment, the student nurse shares the following findings with the primary nurse: Visual fields full to confrontation with Intact extraocular movements. No nystagmus, midline protrusion of tongue, and negative Romberg test. Which of the following will the primary nurse tell the student nurse to document?