The nurse is caring for a client admitted to the hospital with bacterial meningitis that developed after an untreated case of otitis media.  What evaluation alerts the nurse to changes in the client’s intracranial pressure?

What is the priority of care for a client who has had a tonometry exam with an intraocular reading of 55 mm Hg?

The nurse conducts a home visit on 68-year-old male client with Parkinson’s disease following a recent fall 3 days after discharge from an acute care setting. Nurses’ Notes     1000 – Initial post-discharge visit in the client’s home. Met with client and his son. The client has moderate stage Parkinson’s disease and lives with his adult son, who works full-time and provides supportive care. Client reports that he fell on the stairs, attempting to use the second-floor bathroom. Assessment findings: Client is alert and oriented to person, place and time Walks short distances using a walker without problem, but reports that he tires easily Resting tremors noted in both arms and legs Son reports client needs assistance with ADLs on days when rigidity is worse Client reports that he has not slept more than 2 hours per night since discharge   1100 – After a short rest, continued assessment. Blood pressure sitting 138/88, standing 116/60, complains of dizziness on standing Heart rate 86 beats per minute and regular Respirations 16 per minute and unlabored; breath sounds clear bilaterally Temperature 97.2F (36.2C) Strength in legs is diminished bilaterally, but client is able to bear weight using walker Range of motion is within normal limits but rigid in all extremities Client reports frequent urination, “I am sometimes unable to make it to the bathroom” Speech is slow and halted, but understandable Moderate, continuous drooling noted Medications     Lisinopril 40 mg by mouth once daily for hypertension Carbidopa/levodopa 12.5 mg/50 mg 3 times daily by mouth to treat Parkinson’s symptoms   Select all of the findings that need immediate follow-up 

A client who has been treated for status epilepticus in the emergency department will be transferred to the medical unit.  What equipment will the nurse have available in the client’s assigned room?  Select ALL that apply.

The nurse conducts a return home visit 3 months later on 68-year-old male client with Parkinson’s disease and a history of falls. Nurses’ Notes   1000 – Initial post-discharge visit in the client’s home. Met with client and his son. The client has moderate stage Parkinson’s disease and lives with his adult son, who works full-time and provides supportive care. Client reports that he fell on the stairs, attempting to use the second-floor bathroom. Assessment findings: Client is alert and oriented to person, place and time Walks short distances using a walker without problem, but reports that he tires easily Resting tremors noted in both arms and legs Son reports client needs assistance with ADLs on days when rigidity is worse Client reports that he has not slept more than 2 hours per night since discharge   1100 – After a short rest, continued assessment. Blood pressure sitting 138/88, standing 116/60, complains of dizziness on standing Heart rate 86 beats per minute and regular Respirations 16 per minute and unlabored; breath sounds clear bilaterally Temperature 97.2F (36.2C) Strength in legs is diminished bilaterally, but client is able to bear weight using walker Range of motion is within normal limits but rigid in all extremities Client reports frequent urination, “I am sometimes unable to make it to the bathroom” Speech is slow and halted, but understandable Moderate, continuous drooling noted 3-month follow-up assessment Met with client and his son, who both report no falls since the last visit. Client is using the bedside commode during the daytime hours, and only uses the stairs in the evening to go upstairs to sleep. Client reports that he still sometimes feels dizzy when he stands up. Speech is very slow and difficult to understand, and son frequently answers for the client. Episodes of confusion and irritability have been noted during the evening hours. Client demonstrates ability to move within living space with the walker. Medications     Lisinopril once daily for hypertension Carbidopa/levodopa 3 times daily to treat Parkinson’s symptoms Environmental Assessment   Environmental assessment completed by walking through the home with the client. Client reports spending most of his time on the ground floor, aside from the need for toileting (bathroom is on the second floor with stair access). Floors are wood with no noted throw rugs. Walkways are clear of debris.   The nurse returns in 3 months to re-evaluate the client. The statement below indicates that the client’s status has improved, true or false: The client has enrolled in an online yoga class and reports no falls within the last 3 months.

The nurse is teaching the client with Meniere’s disease about controlling symptoms through diet. Which of the following will the nurse emphasize? Select all that apply.

A bolus of mannitol (Osmitrol) is ordered for a client with increased intracranial pressure.  Prior to administration, the urinary output is 40 ml/hr; apical pulse 88; PEARL @3mm; the client is drowsy, but easily aroused.  Which assessment data will best determine the therapeutic effect of the medication?

The Charge nurse observes a fellow staff nurse acting erratically.  The clients assigned to the staff nurse don’t seem to get the relief when pain medications are administered. Which action will the charge nurse take?

Placing the client in the supine position, flexing the head towards the chest, eliciting flexion of the neck, what is the appropriate documentation for the client that displays adduction and flexion of the lower extremities?

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure (IICP) and monitoring for the development of a widening pulse pressure. The current blood pressure is 170/80. What is the client’s pulse pressure? Please record your answer using a whole number.