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.

Answer and Explanation

The Correct Answer is ["He is now quiet and appears sleepy."]

He is now quiet and appears sleepy. This is correct because it indicates a change in the level of consciousness, which could be a sign of increased intracranial pressure or bleeding in the brain.

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Correct Answer is C

Explanation

Febrile. This is incorrect because febrile seizures are associated with high fever and usually occur in children between 6 months and 5 years of age. They are typically generalized and brief, lasting less than 15 minutes.

Absence. This is incorrect because absence seizures are characterized by brief episodes of staring or loss of awareness, without any motor activity or change in level of consciousness.

Complex partial. This is correct because complex partial seizures involve impaired consciousness and automatisms, such as lip smacking, chewing, or fidgeting. They may also involve focal motor activity, such as twitching of one side of the face or body.

Clonictonic. This is incorrect because clonictonic seizures involve alternating muscle contraction and relaxation, resulting in jerking movements of the limbs and trunk. They are usually preceded by a loss of consciousness and followed by a period of confusion or sleepiness

A. Monitor the client's electrolyte levels. B. Suction saliva from the client's mouth. C. Perform passive range of motion on each extremity. D. Record the client's intake and output.

Correct Answer is B

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is observed with unilateral twitching of facial muscles and repetitive tongue thrusting, with a decrease in level of consciousness. When the nurse reports her findings to the physician, what type of seizure will she indicate she observed?

Correct Answer is C

Explanation

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

Correct Answer is B

An 84year old client is brought to the emergency department with reports that his mental status has slowly been declining. He fell 2 weeks ago but did not seek medical attention. Based on this information, what does the nurse suspect the client's diagnosis will be?

A client who suffered a stroke now has functional musculoskeletal deficits and is unable to perform ADLS independently. Which of the following Interventions are appropriate for this client?

A client has a history of atrial fibrillation. Which of the following is the nurse likely to see on the clients medication history to prevent stroke?

A nurse caring for a client who had a rightsided stroke and is exhibiting homonymous hemlanopsia when eating. Which of the following actions should the nurse take?

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?

When considering the client with a neurocognitive deficit, the nurse understands that which of the following are excitatory neurotransmitters?

A nurse is preparing to administer Tissue plasminogen activator (tPA). What is the likely reason the client will receive this treatment?