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 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 nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse Include in the client's plan of care?

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an Indication of Increased Intracranial pressure (ICP)?

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.)

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following is not an appropriate action for the nurse to take?

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

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?

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)

The nurse takes report on a client who was admitted with a severe heada

che, nausea, vomiting, photophobia, and a stiff neck. Which of the following is the priority intervention for the nurse to perform?

After explaining the procedure for an electroencephalograph, which of the following statements by the client indicates teaching was not effective?