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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Wear an eye patch on the right eye at all times."
An eye patch may be recommended alternating between eyes for short periods to relieve diplopia, but wearing it continuously on one eye can lead to eye strain and decreased depth perception.
B. "Implement a schedule to include periods of rest."
Fatigue is a common and debilitating symptom in clients with MS. Scheduling regular rest periods helps prevent overexertion, which can worsen symptoms and increase the risk of relapse.
C. "Engage in a vigorous exercise program."
Vigorous exercise may exacerbate MS symptoms, particularly fatigue and heat sensitivity. Instead, a moderate, low-impact exercise program (e.g., swimming, yoga) is more appropriate.
D. "Plan to relax in a hot tub spa each day."
Heat can worsen MS symptoms (a phenomenon known as Uhthoff’s sign). Hot environments, such as hot tubs or spas, should be avoided to prevent symptom exacerbation.
Correct Answer is B
No explanation
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