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 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 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?

A physician tells the family of a client involved in a motorvehicle accident that the client sustained a coupcontrecoup injury. Which of the following statements by the nurse indicates an understanding of this type of traumatic brain injury?

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

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

A 70year old client diagnosed with a hemorrhagic stroke was admitted 1 day ago. His

medical history includes hypertension, osteoarthritis, and type 2 diabetes. He has right sided

paralysis, garbled speech, and a weak cough reflex. This morning he is restless. Vital signs are Blood Pressure 160/80, pulse 110, respirations 24, oxygen saturation 90% Which of the following Interventions will the nurse take to avoid complications? Select all that apply

Select All that Apply)

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?

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.

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 client with multiple sclerosis has been prescribed interferon B. Which of the following statements indicates the client understands the teaching about this medication.