A 68-year-old male is brought to the emergency department by his family. He was having breakfast when his family noticed sudden changes in his behavior. The patient has a history of hypertension and type 2 diabetes mellitus. Nurses Note Patient presents with signs of stroke that started approximately 30 minutes ago. Blood glucose 120 mg/dL. Stroke alert called. VS and BE FAST assessment completed. Vital Signs BP 180/92 mmHg HR 92 bpm RR 16 breaths/min O2 Saturation 95% on room air Temperature 97.6 F BE FAST Assessment Balance No balance changes Eyes No visual changes Facial Droop Present on right side Arm weakness/numbness Weakness in right arm and leg Speech Slurred speech, slow to respond to verbal commands Time Symptom onset 2 hours ago Which of the following support a diagnosis of a ischemic stroke? Select all that apply.
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Which of the following vital signs demonstrate late findings…
Which of the following vital signs demonstrate late findings of increased intracranial pressure (ICP)?
A nurse is assessing a patient with infective endocarditis,…
A nurse is assessing a patient with infective endocarditis, the nurse notes their Glasgow Coma Scale (GCS) score has changed from 15 to 10 . What is the priority concern?
A patient with systemic lupus erythematosus (SLE) reports fa…
A patient with systemic lupus erythematosus (SLE) reports fatigue, swelling of the extremities, and weight gain. Which complication is the priority concern?
Which of the following patient’s takes highest priority?
Which of the following patient’s takes highest priority?
A patient is diagnosed with an ischemic stroke following a h…
A patient is diagnosed with an ischemic stroke following a head CT. The patient’s symptoms started 1 hour ago. Their BP is 190/110 mmHg. What is the nurse’s priority action?
The nurse is assessing their patient and observe them react…
The nurse is assessing their patient and observe them react to pain with the following motor response. What is the suspected cause of this manifestation?
A patient presents with fatigue, pallor, dyspnea on exertion…
A patient presents with fatigue, pallor, dyspnea on exertion (DOE), and headaches. Which of the following diagnoses in this patient’s medical history does the nurse relate all of these symptoms to?
The nurse is caring for a patient post traumatic brain injur…
The nurse is caring for a patient post traumatic brain injury with a ventriculostomy. During report the patient’s intracranial pressure (ICP) was 12 mmHg. When the nurse returns from receiving report on another patient the nurse notes the ICP is now 16 mmHg. What does this indicate?
All of the following are manifestations of shock except:
All of the following are manifestations of shock except: