Which intervention would the nurse implement as the priority when providing care for a patient with a ventriculostomy to measure increased intra-cranial pressure (ICP) caused by a brain tumor?

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 when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

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?

Which condition would the nurse associate with an infection of a sebaceous gland when the patient presents with a small, white, superficial nodule on the margin of the eyelid?

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?

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?

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying?

A nurse is talking with a client who is scheduled for surgery to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

A nurse is developing a teaching plan for a client who has psoriasis. Which of the following actions should the nurse include in the plan?

A nurse suspects that a client admitted for treatment of bacterial meningitis is experiencing increased intracranial pressure (ICP). Which of the following assessment findings by the nurse supports this suspicion?

A 70-year-old patient brought in the ED by family member after falling off the ladder. His medical history includes hypertension, osteoarthritis, and type 2 diabetes mellitus. Upon nursing assessment, he has laceration on his left side of temple and bruises on left patella. His speech is slightly slurred and a weak cough reflex. Patient is alert and oriented X2 and having restlessness. Vital signs: Blood pressure 152/59, pulse 87, respirations 20. Oxygen saturation is 90% room air. He reported having slight headache and tolerable pain of 3/10 on his left knee.

The nurse is reviewing the client' assessment data to prepare the client's plan of care.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experience. 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.