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. 

The nurse is providing care for a 13-year-old who was placed in a halo brace within the last 24 hours because of a spinal cord injury. Which assessment is the first priority of the nurse?

The nurse is caring for a client with multiple sclerosis (MS) who is having spasticity in the lower extremities that decreases physical mobility. What interventions can the nurse provide to assist with relieving the spasms? Select all that apply.

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.   Which of the following issues is the client at risk of developing?

The nurse is called to a client’s room who has just fallen out of bed. To prevent a spinal cord injury, which priority treatment will the nurse perform?

While initiating a care plan for the client with a ruptured cerebral aneurysm and subarachnoid hemorrhage, which intervention will be included in the care plan?

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?

What is the purpose of the Strange Situation technique?

What is the central focus of Erik Erikson’s psychosocial theory?