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A newly admitted client has a post traumatic brain injury and multiple fractures.  The client’s eyes remain closed, and there is no evidence of verbalization or movement when the nurse performs a sternal rub.  What score on the Glasgow Coma Scale should the nurse document?  Record your answer using whole number

A client with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) is ordered strict I & O. The client has had the following intake during the shift: 8 oz cranberry juice, 1/2 cup oatmeal, 2 slices toast, 12 oz black coffee, tuna fish sandwich, 1 cup fruit flavored jello, 10 oz chicken broth, 8 oz 1% milk and 16 oz of water. What will the nurse record as the client’s fluid intake? DO NOT INCLUDE ml in your answer. 

A 36-year-old client with relapsing-remitting multiple sclerosis is admitted with new increased lower-extremity weakness, incontinence, and blurred vision in the right eye. The client usually walks independently, now requires two-person assistance. This morning, the nurse notes that the client has a flat affect, frequently refuses physical therapy, and states, “What’s the point? Every time I start to get better, I just get worse again.” Which of the following is the most important priority within the plan of care? 

The nurse is preparing a client with multiple sclerosis for discharge from the hospital to home. Which of the following instructions is most appropriate when teaching this client?

H&P: 24 y/o healthy male comes to the emergency department (ED) after a motor vehicle accident (MVA). Transported to the ED via a spinal backboard and with a cervical collar to maintain head and neck alignment. Per emergency services, the client was unconscious at the site of the MVA and regained consciousness after 4 minutes. Client has since awakened and is ALOx3, moving all extremities. Client c/o dull headache, dizziness, and unable to remember how the accident occurred. No visual changes, weakness, or incontinence. No significant past medical or surgical history, except for a concussion during high school while playing contact football. Denies alcohol, tobacco, or illicit drug use.  Physical Assessment:  1/18/22 at 0943: VS as followed: 99.2F, Pulse: 98 and regular, Blood pressure: 134/81mmHg, and respirations: 20 and regular. ALOx3. GSC: 15. Skin has scattered bruising and scabs. Pupils equal and reactive, periorbital ecchymosis present. Heart and lung sounds normal. Head normocephalic with mild swelling to the basilar area of the head. Neck exam WNL w/ full range of motion. Abd soft, nontender, with positive bowel sounds.    For each finding, specify if the finding is a risk factor or not a risk factor for spinal injury.

A nurse educator is educating new nurses about the various medications used to manage seizure disorders. Which of the following medications should the nurse include as commonly used for the treatment of seizures? Select all that apply

A nurse educator is educating new nurses about the various medications used to manage seizure disorders. Which of the following medications should the nurse include as commonly used for the treatment of seizures? Select all that apply

H&P: 24 y/o healthy male comes to the emergency department (ED) after a motor vehicle accident (MVA). Transported to the ED via a spinal backboard and with a cervical collar to maintain head and neck alignment. Per emergency services, the client was unconscious at the site of the MVA and regained consciousness after 4 minutes. Client has since awakened and is ALOx3, moving all extremities. Client c/o dull headache, dizziness, and unable to remember how the accident occurred. No visual changes, weakness, or incontinence. No significant past medical or surgical history, except for a concussion during high school while playing contact football. Denies alcohol, tobacco, or illicit drug use.  Physical Assessment:  1/18/22 at 0943: VS as followed: 99.2F, Pulse: 98 and regular, Blood pressure: 134/81mmHg, and respirations: 20 and regular. ALOx3. GSC: 15. Skin has scattered bruising and scabs. Pupils equal and reactive, periorbital ecchymosis present. Heart and lung sounds normal. Head normocephalic with mild swelling to the basilar area of the head. Neck exam WNL w/ full range of motion. Abd soft, nontender, with positive bowel sounds.    For each finding, specify if the finding is a risk factor or not a risk factor for spinal injury.

The client is a 63-year-old female who arrived via emergency services with right-sided weakness, right facial droop, and slurred speech.  History and Physical History: Diabetes mellitus type II, hypertension, and rheumatoid arthritis. Spouse is answering questions for her at the bedside. Per spouse, the client has experienced recent increased stress and does not monitor her blood pressure. The client was in her usual health the night prior. She woke up around 0500 and having a typical morning until approximately 0630 when she noticed that she wasn’t able to hold her brush with her right hand. Spouse states he noticed that her face was also drooping at that time and called 911. Nurses Note: 07/05/20XX 0712: Client arrived and stroke alert initiated. Client is alert and oriented x 3 with slurred speech and aphasia. Client unable to lift or maintain gravity in right arm and right leg. Drooping to the right side of the face noted. Healthcare provider at bedside.    Nurses Note 7/5/20XX 0745:  The client is able to speak a few words and states that she has a history of atrial fibrillation and her gallbladder removed 4 months ago. The client begins to moan, hold her head, and complains of extreme pain in the back of her head. The lab has called with the stat laboratory results:   Lab Result Reference Range White blood cell 6.4 4.5-11 per microliter Hemoglobin 13.3 12-16 g/dL Hematocrit 39 38-46% Platelet 180,000 150,000-45000/microliter PT 11 11-13.5 seconds INR 1.1 0.8-1.2      Vitals 07/05/20XX 0712:   Temp: 98.6*F Pulse: 99 Respirations: 22 Blood Pressure: 180/118 O2 Saturation: 98% on Room Air 07/05/20XX 0810 – Client to radiology for CT without contrast. CT results: no evidence of hemorrhage.   07/05/20XX 0820: Client returns from Radiology and placed on bedside telemetry monitoring. Client remains in Atrial fibrillation. Healthcare provider at the bedside and orders to lower the blood pressure before administering thrombolytic to reduce the risk of hemorrhage. 07/05/XX 0830 – Client resting quietly. Right side remains weak, unable to maintain gravity in right arm and right leg, speech is slurred with some word finding difficulty. Client is frustrated and tearful. Remains in A-fib on the monitor with a rate of 90. Healthcare provider orders to administer thrombolytic – Tenecteplase 20 mg IV. Vitals: Temp: 98.6*F Pulse 90 Respirations: 20 Blood Pressure: 141/89 Oxygen Saturation: 98% on Room Air.    Following the administration of Tenecteplase, which symptoms would have priority to alert the health care provider? Select all that apply.

After receiving a sternal rub, a client demonstrates an extension of the upper left arm and rigidly extended left leg with plantar flexion. The nurse documents this response as: