After an older adult falls, the nurse suspects the development of a subdural hematoma based on which finding(s)? (Select all that apply.)
a. Increasing irritability
b. Complaint of a dull headache
c. Frequent "nodding off" in chair during the day
d. Focal seizures
e. Staggering gait
A, B, C
Increasing irritability and complaint of headache as well as changing level of consciousness are signs of increasing intracranial pressure. Seizures and staggering gait are not specifically indica-tive of subdural hematoma.
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During an interview, the patient states he has the sensation that "everything around him is spinning." The nurse recognizes that the portion of the ear responsible for this sensation is the:
a. Cochlea. b. CN VIII. c. Organ of Corti. d. Labyrinth.
The nurse determines that a client with narcissistic personality disorder has met a goal of treatment when:
1. the client asks to watch TV after-hours. 2. the client follows unit rules. 3. the client enters the nurse's lounge. 4. the client raids the unit refrigerator.
Which assessment finding for a 4-month-old infant would require further action by the nurse?
1. The posterior fontanel is open. 2. The infant has good head control when held upright. 3. The infant is able to roll only from abdomen to back. 4. The anterior fontanel is open and soft.
A patient's serum electrolytes are being monitored. The nurse notices that the potassium level is low. What should the nurse monitor for in this patient?
a. Tissue ischemia b. Brain malformations c. Intestinal blockage d. Cardiac dysrhythmia