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.

The nurse is examining an unconscious client.  During the examination, the nurse notes that the client’s pupils are fixed and dilated.  What is the clinical significance of the nurse’s assessment?

A 74-year-old female client is brought into the clinic their spouse. The client has had periods of disorientation and weakness.  The admitting nurse assesses that this client is dressed appropriately but that the makeup on one side of their face is smeared, and their hair is combed on one side of their head only and only one of their shoes are tied.  What condition do these findings indicate?

The nurse explains to the client with a stroke who is scheduled for an angiogram that this test is used to determine which one of the following?

The nurse is assisting with a lumbar puncture and observes that when the physician obtains cerebrospinal fluid (CSF), it is clear and colorless.  What does this finding indicate?

A client with a subarachnoid hemorrhage secondary to ruptured cerebral aneurysm has been placed on aneurysm precautions.  To provide a safe environment, the nurse will implement which of the following interventions?  Select all that apply.

The nurse is making rounds after receiving change of shift report.  Which of the following clients will the nurse see first?

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.