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 caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority?

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?

When providing education to a student nurse about ways to avoid increased intracranial pressure, which of the following will the nurse include in the instructions?(Select All that Apply.)

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 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 monitoring the vitals of a client who has a traumatic brain injury. Which of the following indicate that the client is in stage 3 of increased Intracranial pressure? Select all that apply
(Select All that Apply.)

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

A client reports visual disturbances followed by debilitating pain, nausea, and light sensitivity. When providing education for this client, what can the nurse include in teaching?

Select all that apply (Select All that Apply.)

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

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?