Please could yall answer them for me.. tell me what you think

Nursing Students NCLEX

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A 65-year-old man is admitted to the emergency department (ED) after a fall from a ladder. A nursing history reveals that while he was helping a friend fix his roof on a very hot day, he drank several beers.On assessment you find that he is alert and oriented but reports that his head is sore. No swelling, bruising, or bleeding is evident. His vital signs are blood pressure of 154/86, Heart rate of 58, respirations of 20, oxygen saturation of 96% on room air, and oral temperature of 98.8 degrees Fahrenheit. He has a history of hypertension and diabetes mellitus, which are controlled by drug therapy and diet. His wife tells you that he doesn't always take his medication and that he drinks "a lot."

What does this patient's vital signs mean to you as a nurse.

I am thinking ICP or alcohol withdrawal due to vs

His heart rate is too slow and due to the hot weather and the work he is probably dehydrated. Alcohol in large amounts constricts blood vessels which decreases circulation and also increases the blood pressure. All that causes poor perfusion of the major organs, especially the brain. To me it sounds like a heart block that he usually tolerates but due to the circumstances, which lead to poor perfusion, he fainted.

Increse icp

You will not see any long questions like this on the NCLEX.

Possibly a subdural hematoma... in light of the fall and headache.... he would have a risk factor as a alcoholic (cerebral atrophy).

his obs--- I dont really know-- he is tachypneic, hypertensive....

where is the question actually going with this?

Specializes in PICU, Sedation/Radiology, PACU.

Google "Cushings Triad." That should point you in the right direction.

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