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

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? 

When caring for the client with Alzheimer's disease, which of the following are appropriate items to include in the client's room?

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 nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?

Which of the following clients is most at risk for traumatic brain injury?

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 nurse is caring for a client who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?

The nurse caring for a client with a brain tumor will monitor for which of the following early signs of increased intracranial pressure?

According to the ATI video case study, Cognition: Delirium and Dementia, which of the following is the best first action for the nurse to take when caring for a client with delirium?