[Answered]: Please I need help with the care plan

Please I need help with the care plan. Mr. TC with Recent Fall and Altered Mental Status Patient Profile: Name: TC Age: 76 Sex: Male Medical History: Hypertension, Ischemic Stroke (2 years ago), Left-sided weakness, recent fall (within 6 hours), forgetfulness Presenting Complaints: Severe headache, chest pain, disorientation (cannot recall home address) Height 56 weighs 306 pounds DNR/DNI Religion Catholic goes to church on Wednesdays prefers though early morning mass praise before every meal and very superstitious. ambulates with a cane 1800 ADA, low sodium diet, chopped Meds: lisinopril 20 mg orally twice daily atorvastatin 40 mg orally daily baby ASA 81 mg orally daily Aricept 5 mg orally daily Initial Assessment: Vital Signs: BP: 190/104 mmHg HR: 94 bpm RR: 22 breaths/min Temp: 37.2C O2 Sat: 94% on room air Physical Exam: Left-sided weakness noted Unsteady gait Confused and disoriented to place Pupils equal and reactive Mild facial droop on the left *ECG: Non-ST elevation changes *FAST (stroke screen): Facial droop, Arm drift, Speech difficulty present *GCS: 13 (Eye 4, Verbal 4, Motor 5) Focused Questions and Answers: Q1: What is the priority nursing diagnosis? Q2: What are the next steps in the ER? (what test will be ran? What labs do you anticipate to be drawn)? What precautions will he be put on? What will be checked every four hours and what monitoring will he be placed on? Q3: What could be the cause of the severe headache and confusion? What therapy, can he anticipate for his discharge? What referrals would you make? The starred information is something you haven’t been taught yet, but look it up for future reference.