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 at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

A nurse is caring for a client who has an epidural hematoma. Which of the following manifestations should the nurse expect?

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?

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?

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 is in a client's room when the client begins having a tonicclonic seizure. Which of the following actions should the nurse take first?

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 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?

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 is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?