When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min

BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min

BP 172/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min

Answer and Explanation

The Correct Answer is D

A.   BP 126/54 mm Hg, pulse 58 beats/min, respirations 10 breaths/min - While the low pulse and respirations should be assessed, this blood pressure isn't as concerning.
B.   BP 112/56 mm Hg, pulse 98 beats/min, respirations 28 breaths/min - These vital signs are within a safer range compared to the critical changes in D.
C.   BP 129/65 mm Hg, pulse 60 beats/min, respirations 20 breaths/min - These are stable vital signs.
D.   The BP of 172/54 mm Hg, combined with bradycardia (pulse of 58 beats/min) and hypoventilation (respirations of 10 breaths/min), is indicative of Cushing's triad, a late sign of increased intracranial pressure, which is an emergency requiring immediate attention.

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Correct Answer is B

Explanation

A. Hyperopia (farsightedness) causes difficulty seeing close objects.
B. Myopia, or nearsightedness, causes difficulty seeing distant objects clearly while nearby objects remain clear.
C. Astigmatism results in blurred vision at all distances due to an irregularly shaped cornea.
D. Presbyopia is age-related difficulty in focusing on near objects due to lens rigidity.

A. Poor judgment B. Intellectual impairment C. Loss of depth perception D. Impaired sense of humor

Correct Answer is B

Explanation

A. Poor judgment: Poor judgment is more likely to be seen with a stroke in the right hemisphere.
B. Intellectual impairment: A stroke in the left hemisphere can cause cognitive and intellectual deficits, especially in language and reasoning.
C. Loss of depth perception: Loss of depth perception is typically seen with right-sided strokes, not left- sided.
D. Impaired sense of humor: This is more common in right-sided strokes affecting the emotional and social aspects of the brain.

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When the patient's initial vital signs after a brain injury were a BP of 132/72 mm Hg, pulse 100 beats/min, respirations 24 breaths/min, which subsequent vital signs would the nurse report immediately to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which refractive error describes the vision of a patient for whom nearby objects are clear but objects at a distance are blurred?

Correct Answer is B

Explanation

A nurse is caring for a client who had a stroke involving the left cerebral hemisphere. The nurse should monitor for which of the following findings?

Correct Answer is B

Explanation

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