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 student nurse is asked by the preceptor to identify which of the assigned clients is at the highest risk for stroke. Which of the clients below, when selected by the student nurse, indicate an understanding of the highest risk factor for stroke?

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?

A nurse is caring for a client with a closed skull injury who has an intracranial pressure (ICP) reading consistently over 20 mmHg, According to the MonroeKellie Doctrine, If Intracranial pressure continues to Increase, what will occur? Select All that Apply.

A client arrived by EMS after a bar fight. He is disoriented with a Glasgow coma scale of 10.

 What additional finding indicates that he has suffered a basilar skull fracture? 

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?

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?

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?

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

A nurse is providing education to a group of older adults about the risk of stroke. Which selections made by the group indicate an understanding of the teaching? Select All that Apply (Select All that Apply.)

The nurse caring for a client with a brain tumor will monitor for which of the following early signs of increased intracranial pressure?