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?

You admit a client on day 1. After several days off, you are reassigned the same client. Click the tabs to review vital signs and nurse notes to review the client's progression.

Vital Signs Assessment Day 1:

Temperature 37.5° C (99.5° F) Blood pressure 198/96 mm Hg Heart rate 112/min

Respiratory rate 22/min

Oxygen saturation 96% on room air Day 7:

Temperature 38° C (100,4° F) Blood pressure 166/70 mm Hg Heart rate 68/min

Respiratory rate 20/min

Oxygen saturation 97% on room air

Question: For each client finding, click to specify if the finding could indicate Parkinson's disease, stroke, and/or multiple sclerosis. Each finding can support more than one disease process. Click the tabs at the top of the page for information about your client.

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?

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 providing teaching to the family of a client who has Parkinson's disease. Which of the following information should the nurse include in the teaching?

A client is extremely drowsy, minimally responsive, and has a difficult time following commands. With vigorous stimulation the client awakens but quickly falls back asleep. What level of consciousness does this describe?

You are monitoring the vital signs of an 74yrold man who was admitted for a head injury after he tripped and fell at home. He takes anticoagulants for atrial fibrillation. On arrival his vital signs were stable at BP 150/86, pulse 84, respirations 14/min, but his family reported that he was more restless than usual. He lives alone after his wife passed away. 2 hours after admission, his vital

signs are now BP 166/74, pulse 54, respirations 11/min. He is now quiet and appears sleepy. He is on 2L nasal cannula and has been placed on neutropenic precautions.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis. Assessment findings include nuchal rigidity and a petechial rash. After Implementing droplet precautions, which of the following actions should the nurse initiate next?

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 nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)