A nurse is caring for a 20-year-old client who has a fever and reports severe headache. Vital Signs at 0800 Temperature 38.9° C (102° F); Tympanic Apical pulse 118/min; strong and regular Respirations 20/min; even and unlabored  Blood pressure 114/78 mm Hg  Oxygen saturation 97% on room air Nurses Notes 0800: Client reports missing classes at a local community college the last two days due to fever and headache. Rates pain with headache as a 9 on a scale of 0 to 10. Verbalizes that headache was not relieved by acetaminophen or ibuprofen taken at home. Client awake, alert, and oriented to person, place, and time. Pupils equal, round, and reactive to light. Temperature elevated.  Skin warm and dry, face flushed.  Petechiae noted on trunk.  Reports nausea and vomiting frequent for the last 24 hr. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present.  Nuchal rigidity noted.  Brudzinski’s sign positive. Respirations easy and unlabored.  Lungs clear to auscultation.   1000 Vital Signs Temperature 38.9° C (102° F); Tympanic Apical pulse 50/min; strong and regular Respirations 10/min; even and unlabored  Blood pressure 190/105 mm Hg  Oxygen saturation 97% on room air 1000 Nurses notes: Assessment completed after lumbar puncture. Client awake, restless, confused, and oriented to person only. Pupils equal, round, and reactive to light. Temperature elevated.  Skin warm and dry, face flushed.  Petechiae noted on trunk. Decerebrate posturing noted. Occasional vomiting. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present.  Nuchal rigidity noted.  Brudzinski’s sign positive. Respirations easy and unlabored.  Lungs clear to auscultation.   Out of each assessment finding, please select the findings that indicate the client’s status has declined. PLEASE SELECT ALL THAT APPLY. 

The client is scheduled for an EEG (electroencephalogram) in the morning. What foods will the nurse instruct the client to avoid before the test? Select all that apply.

While riding a skateboard, the client has sustained a concussion. What is the nurse’s priority in providing care for this client?

A nurse is caring for a 20-year-old client who has a fever and reports severe headache. Vital Signs at 0800 Temperature 38.9° C (102° F); Tympanic Apical pulse 118/min; strong and regular Respirations 20/min; even and unlabored  Blood pressure 114/78 mm Hg  Oxygen saturation 97% on room air Nurses Notes 0800: Client reports missing classes at a local community college the last two days due to fever and headache. Rates pain with headache as a 9 on a scale of 0 to 10. Verbalizes that headache was not relieved by acetaminophen or ibuprofen taken at home. Client awake, alert, and oriented to person, place, and time. Pupils equal, round, and reactive to light. Temperature elevated.  Skin warm and dry, face flushed.  Petechiae noted on trunk.  Reports nausea and vomiting frequent for the last 24 hr. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present.  Nuchal rigidity noted.  Brudzinski’s sign positive. Respirations easy and unlabored.  Lungs clear to auscultation.   The nurse should address the client’s ___________ followed by the client’s ____________.

The nurse is providing care for the client experiencing aphasia. Which of the following nursing interventions are appropriate? Select all that apply.

The client is experiencing right-sided hemiparesis and homonymous hemianopia due to a CVA. What is the visual field defect that this client is experiencing?

During admission of a client to the emergency department with a severe head injury, the nurse places the highest priority on assessment for which of the following?

An unconscious client receiving emergency care following an automobile crash accident has a possible spinal cord injury. What priority interventions for emergency care will be followed? Select all that apply. 

A client with a recent CVA is receiving an IV Heparin drip.  Which lab test must the nurse check frequently?

A client with carotid atherosclerosis is scheduled to have a carotid endarterectomy, and asks the nurse about questions about this procedure.  Which response by the nurse is the most accurate?