A student nurse is caring for a client with acute hemorrhagic stroke who was admitted 1 day ago. Which is the priority assessment finding for the student to report to the primary nurse?

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?

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?

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 is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?

A student nurse is asked by the preceptor to identify which of the assigned clients is at the highest risk for stroke. Which of the clients below, when selected by the student nurse, indicate an understanding of the highest risk factor for stroke?

A nurse suspects that a client has increasing intracranial pressure. Which of the following diagnostics does the nurse anticipate will be ordered?

A nurse is assessing a client who has a score of 6 on the Glasgow Coma Scale. The nurse should expect which of the following outcomes based on this score?

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 suspected of having a stroke is scheduled to have an angiogram. Which of the following is a priority action for the nurse?

When considering the client with a neurocognitive deficit, the nurse understands that which of the following are excitatory neurotransmitters?