Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm Hg, pulse of 110 beats/min, and of respirations 26 breaths/min. Which set of vital signs, if taken 1 hour later, will be of most concern to the nurse?

When a brain-injured patient responds to nail bed pressure with internal rotation, adduction, and flexion of the arms, how would the nurse report the response?

The nurse has administered prescribed IV mannitol (Osmitrol) to an unconscious patient. Which parameter would the nurse monitor to determine the medication‘s effectiveness?

A patient with a head injury opens his eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to push away a painful stimulus. How would the nurse record the patient‘s Glasgow Coma Scale score?

An unconscious patient is admitted to the emergency department (ED) with a head injury. The patient‘s spouse and teenage children stay at the patient‘s side and ask many questions about the treatment. Which action is best for the nurse to take?

A patient who is unconscious after a head injury has cerebral edema. Which nursing intervention will be included in the plan of care?

A 20-yr-old is admitted with a head injury after a collision while playing sports. After noting that the patient has developed clear nasal drainage, which action would the nurse take?

Which action will the emergency department nurse anticipate for a patient diagnosed with a concussion who did not lose consciousness?

A patient who has a suspected epidural hematoma is admitted to the emergency department. Which action will the nurse expect to take?

The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patient‘s nose. Which admission order would the nurse question?

An athlete is seen in the clinic 6 weeks after a concussion. Which assessment information will the nurse collect to determine whether the patient is developing post-concussion syndrome?

When assessing a patient who has a right frontal lobe tumor, which finding would the nurse expect?

Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse?

After having a craniectomy and left anterior fossae incision, a patient has weakness, impaired physical mobility, and a decreased level of consciousness. Which nursing action will be included in the plan of care?

A patient who has bacterial meningitis is disoriented and anxious. Which action will the nurse include in the plan of care?

The public health nurse is planning a program to decrease the incidence of meningitis in teenagers and young adults. Which action is most likely to be effective?

A patient has been admitted with meningococcal meningitis. Which observation by the nurse requires action?

When assessing an adult who has bacterial meningitis, the nurse obtains the following data. Which finding requires the most immediate intervention?

A patient admitted with a diffuse axonal injury has a systemic blood pressure (BP) of 106/52 mm Hg and an intracranial pressure (ICP) of 14 mm Hg. Which action would the nurse take first?

After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action would the nurse take first?

Which patient is most appropriate for the intensive care unit (ICU) charge nurse to assign to a registered nurse (RN) who has floated from the medical unit?

A patient who has possible cerebral edema has a serum sodium level of 116 mEq/L (116 mmol/L) and a decreasing level of consciousness (LOC). The patient is now reporting a headache. Which prescribed intervention would the nurse implement first?

After the emergency department nurse has received a status report on the following patients with head injuries, which patient would the nurse assess first?

The nurse is caring for a patient who was admitted the previous day with a basilar skull fracture after a motor vehicle crash. Which assessment finding indicates a possible complication that should be reported to the health care provider?

After evacuation of an epidural hematoma, a patient‘s intracranial pressure (ICP) is being monitored with an intraventricular catheter. Which information obtained by the nurse requires urgent communication with the health care provider?

The charge nurse observes a new staff nurse caring for a patient who has had a craniotomy for resection of a brain tumor. Which action by the new nurse requires the charge nurse to intervene?

A patient is brought to the emergency department (ED) by ambulance after being found unconscious on the bathroom floor. Which action will the nurse take first?

The nurse is caring for a patient who has a head injury. Which finding, when reported to the health care provider, would the nurse expect will result in new prescribed interventions?

While admitting a patient with a possible brain injury to the emergency department (ED), the nurse obtains the following information. Which finding is most important to report to the health care provider?

A patient being admitted with bacterial meningitis has a temperature of 102.5F (39.2C) and a severe headache. Which prescribed intervention would the nurse implement first?

Which question will the nurse ask a patient who has been admitted with a benign occipital lobe tumor to assess for related functional deficits?

During change-of-shift report, the nurse learns that a patient with a head injury has decorticate posturing to noxious stimulation. Which positioning shown in the accompanying figure will the nurse expect to observe?

Which is the correct point on the accompanying figure where the nurse will assess for ecchymosis when admitting a patient with a basilar skull fracture?

The nurse would determine that teaching about migraine headaches has been effective when the patient says which of the following?

Which finding would the nurse expect when assessing a patient who is experiencing a cluster headache?

While the nurse is transporting a patient on a stretcher to the radiology department, the patient begins having a tonic-clonic seizure. Which action would the nurse take?

A high school teacher who has been diagnosed with epilepsy after having a generalized tonic-clonic seizure tells the nurse, “I cannot teach any more. It will be too upsetting if I have a seizure at work.” How would the nurse respond to specifically address the patient‘s concern?

A patient has been taking phenytoin (Dilantin) for 2 years. Which action would the nurse take when evaluating possible adverse effects of the medication?

Which action would the nurse plan to take for a patient with multiple sclerosis who has urinary retention caused by a flaccid bladder?

A patient with Parkinson‘s disease (PD) has bradykinesia. Which action would the nurse include in the plan of care?

Which recommendation would the nurse provide to a patient with myasthenia gravis (MG)?

Which medication taken at home by a patient with restless legs syndrome would the nurse discuss with the patient?

A patient who has amyotrophic lateral sclerosis (ALS) is hospitalized with pneumonia. Which action would the nurse include in the plan of care?

A 40-yr-old patient is diagnosed with early Huntington‘s disease (HD). What information would the nurse provide when teaching the patient, spouse, and adult children about this disorder?

A 22-yr-old patient seen at the health clinic with a severe migraine headache tells the nurse about having similar headaches recently. Which initial action would the nurse take?

The nurse is providing discharge instructions to a client diagnosed with cirrhosis and varices. Which information would the nurse include in the teaching session? Select all that apply.

The nurse is caring for a client that is scheduled to have a percutaneous liver biopsy. Which assessment findings warrant the postponement of the procedure? Select all that apply. a) b) c)

The nurse is caring for a client with hepatic encephalopathy and ascites. Which elements are important to include in the client's diet? Select all that apply.

The nurse is caring for a client with cirrhosis of the liver. The nurse anticipates a prescription for neomycin enemas based on which abnormal laboratory test?

A client with cirrhosis of the liver and ascites is scheduled to have a paracentesis. Which intervention would the nurse do to prepare the client for the procedure?

A nurse is explaining the pathophysiology of septic shock to a new graduate nurse. Which statements accurately describe the underlying mechanisms? (Select all that apply.)

A patient received a kidney transplant last month. Because of the effects of immunosuppressive drugs and CKD, what complication of transplantation should the nurse be assessing the patient for to decrease the risk of mortality?

A patient with acute kidney injury (AKI) is being evaluated as a candidate for continuous renal replacement therapy (CRRT). Which of the following are the most common indications for CRRT? (Select all that apply)

Which client is at the highest risk for developing acute renal failure (ARF)?

A client with acute renal failure has a potassium level of 6.5 mEq/L. Which action should be assigned to the first-year student nurse?

A 68-year-old man with a history of heart failure resulting from hypertension has AKI as a result of the effects ofnephrotoxic diuretics. Currently his serum potassium is 6.2 mEq/L (6.2 mmol/L) with cardiac changes, his BUNis 108 mg/dL (38.6 mmol/L), his serum creatinine is 4.1 mg/dL (362 mmol/L), and his serum HCO3− is 14 mEq/L(14 mmol/L). He is somnolent and disoriented. Which treatment should the nurse expect to be used for him?

An 83-year-old female patient was found lying on the bathroom floor. She said she fell 2 days ago and has not been able to take her heart medicine or eat or drink anything since then. What conditions could be causing prerenal AKI in this patient (select all that apply)?

What are intrarenal causes of acute kidney injury (AKI) (select all that apply)?

Which dietary recommendation is most appropriate for a client in the oliguric phase of acute renal failure?

Which of the following medications should the nurse question in a client with acute renal failure?

A patient with sepsis is receiving aggressive fluid resuscitation with normal saline. Which finding would indicate that the treatment is effective?

When admitting an acutely confused patient with a head injury, which action would the nurse take?

Which item would the nurse include in a focused assessment of a patient‘s left posterior temporal lobe functions?

How would the nurse assess the patient‘s trigeminal and facial nerve function (CNs V and VII)?

Which action would the nurse include in the plan of care for a patient with impaired function of the left glossopharyngeal nerve (CN IX) and vagus nerve (CN X)?

To prevent autonomic dysreflexia, which nursing action would the home health nurse include in the plan of care for a patient who has paraplegia at the T4 level?

A patient with a history of T3 spinal cord injury is admitted with dermal ulcers. The patient tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action would the nurse take first?