The nurse is caring for a client following a hemorrhagic cerebral vascular accident. Which risk factor should the nurse help the client develop a plan to change?

What cranial nerve is the LPN/LVN assessing when touching a tongue depressor to the back of the pharynx to elicit the gag reflex?

A client who suffered a hemorrhagic stroke has dysphagia and is prescribed a soft diet with nectar thick liquids. Which item should the client be instructed to avoid?

A client is admitted with a possible head injury.  Vital signs on admission were: Blood pressure: 128/72 mm Hg Pulse: 90 beats/min Respirations: 16 breaths/min O2 saturation: 98% of room air Temperature: 37°C  One hours after admission, the nurse reassessed vital signs. Which of the following new vital sign findings listed below indicates a late sign of increasing intracranial pressure?

A client arrives at the emergency department complaining of a migraine. They are uncertain what caused it.  What instruction will the nurse give?

A client is admitted to the hospital with a diagnosis of meningococcal meningitis. Which safety intervention will the nurse complete?

The nurse enters the client’s room and notes the client looking spontaneously around the room. The client is able to state their name, date of birth, and allergies when prompted for that information.  The nurse asks for permission to assess the client’s vitals and the client lifts the right arm for the nurse to apply the blood pressure cuff. The client’s blood pressure is 114/72 mm Hg, heart rate is 81, respiratory rate is 16, and temperature is 37.9°C. The client rates their pain a 2/10 and describes it as a dull ache behind the left eye.  What is the client’s Glasgow Coma Scale score? Write the number in the blank below. 

The nurse is preparing to complete a health history for a client admitted to the medical-surgical unit to rule out Guillain-Barre syndrome. The nurse will ask which question?

The nurse is assessing a client admitted to the medical-surgical unit with a diagnosis of bacterial meningitis. Which clinical manifestations can the nurse find upon assessment? Select all that apply. 

The nurse is caring for a client is diagnosed with a traumatic brain injury.  Which therapeutic measure should the nurse anticipate implementing?