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 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?

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?

Match the characteristics with the type of stroke. Each characteristic is only used one time.

• Hypertension primary Cause

• Symptoms progress over time

• Rapid progression of symptoms

• Most common type

• Symptoms resolve

• Associated with high risk of stroke

• Atrial fibrillation primary cause

Type of stroke

a.Transient Ischemic Attack b.Hemorrhagic Stroke c.Ischemic Stroke

A nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. Which of the following foods should the nurse eliminate?

A nurse is caring for a client who has rightsided acoustic neuroma resulting in impairment of cranial nerves IX and X. Which of the following actions should the nurse take?

A client reports visual disturbances followed by debilitating pain, nausea, and light sensitivity. When providing education for this client, what can the nurse include in teaching?

Select all that apply (Select All that Apply.)

A nurse is performing a neurological assessment for a client with head trauma. Which of the following assessments will give the nurse information about the function of cranial nerve II?

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 monitoring the vitals of a client who has a traumatic brain injury. Which of the following indicate that the client is in stage 3 of increased Intracranial pressure? Select all that apply
(Select All that Apply.)

A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?