Which are components of a secondary intracranial injury? Select all that apply.

When performing a focused assessment on a patient with a lesion of the left posterior temporal lobe, the nurse will assess for

Assessment of a client’s visual acuity reveals that with his left eye he can see 30 feet what a person with normal vision can see at 70 feet and with his right eye he can see 40 feet what the person with normal vision can see at 60 feet. How would the nurse record these findings?

Which nursing intervention is most appropriate for facilitating communication with a patient who has a hearing impairment?

The nurse is calculating the cerebral perfusion pressure (CPP) of an unconscious patient. The patient’s blood pressure is 162/58 mm Hg and intracranial pressure (ICP) is 35 mm Hg. What is the patient’s CPP? Record your answer using a whole number. 

After providing education to a patient with otosclerosis, the nurse determines that the teaching was effective when the patient states that the hearing loss is due to what?

The nurse is caring for an older adult patient. Which gerontologic findings of the visual system does the nurse anticipate may be present? Select all that apply.

The nurse suspects a patient has increased intracranial pressure. Which assessment findings may indicate this condition? Select all that apply.

The nurse is caring for a patient with altered function of the lungs and digestive system. Which cranial nerve should the nurse assess?

A patient with a head injury opens the eyes to verbal stimulation, curses when stimulated, and does not respond to a verbal command to move but attempts to remove a painful stimulus. The nurse records the patient’s Glasgow Coma Scale score as