A 55-year-old male client is brought to the emergency department by his spouse due to sudden weakness, dizziness, and confusion. The spouse states that the client has had persistent fatigue and nausea for the past few days but suddenly became disoriented and lethargic this morning. The client also reports severe abdominal pain and muscle cramps.

Exhibits

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

• Place the call light within the client's reach. The client has undergone surgery on the left hemisphere of the brain, which controls speech and motor function on the right side. This may lead to temporary weakness or speech difficulties, making it essential to ensure easy access to the call light for assistance.
• Use a word board to help the client communicate. Damage to the left hemisphere can result in Broca aphasia, where the client has difficulty producing speech but can still understand language. A word board or communication aid allows the client to express needs effectively despite speech limitations.
• Cerebral perfusion pressure. Monitoring cerebral perfusion pressure (CPP) is essential after brain surgery to ensure the brain is receiving adequate blood flow. Low CPP can lead to ischemia, while high CPP may indicate increased intracranial pressure (ICP), both of which can result in serious complications.
• Level of consciousness. Assessing neurological status frequently helps detect early signs of deterioration, such as worsening intracranial pressure, cerebral edema, or postoperative bleeding. Changes in alertness, responsiveness, or confusion may indicate a need for urgent intervention.
• Broca aphasia. Since the left hemisphere controls speech production, surgery in this area may cause Broca aphasia, where the client understands language but struggles to form words or complete sentences. The use of alternative communication methods is necessary to assist the client in expressing their needs.
• Prepare the client to return to surgery. There is no indication of complications requiring an immediate return to the operating room. The estimated blood loss (100 mL) is minimal, and vital signs remained stable throughout the procedure.
• Give ibuprofen as ordered. Ibuprofen (a nonsteroidal anti-inflammatory drug - NSAID) is contraindicated postoperatively because it can increase the risk of bleeding by inhibiting platelet function. Acetaminophen is typically preferred for pain control.
• Elevate the head of the bed to 45 degrees. After brain surgery, the head of the bed should be elevated to 30 degrees, not 45 degrees. This optimizes cerebral venous drainage while preventing excessive intracranial pressure (ICP) changes that could impair perfusion.
• White blood cell count. WBC count may be monitored for infection, but immediate concerns after brain surgery focus on neurological status and cerebral perfusion rather than infection unless symptoms of fever or worsening condition develop.
• Pupil response. While pupil assessment is a key neurological parameter, it is more relevant for clients at risk of brain herniation or severe ICP elevation. In this case, monitoring level of consciousness and cerebral perfusion pressure takes priority.
• Deep tendon reflexes. Reflex testing is not a primary concern after brain surgery unless there are signs of spinal cord involvement or a progressive neurological disorder. Monitoring motor function and speech ability is more relevant.
• Myasthenia gravis. Myasthenia gravis is an autoimmune neuromuscular disorder that causes muscle weakness but is unrelated to brain tumor removal.
• Cushing response. Cushing's response is a late sign of increased intracranial pressure (ICP), characterized by hypertension, bradycardia, and irregular respirations. The client has no signs of worsening ICP at this time.
• Hydrocephalus. Hydrocephalus is excess cerebrospinal fluid (CSF) accumulation, which typically requires a shunt or external ventricular drain (EVD). There is no indication of CSF buildup in this client.

A. Respiratory rate of 26 breaths/minute. A respiratory rate ≥22 breaths/minute meets the SIRS criteria and indicates systemic inflammation or respiratory distress. In pneumonia, increased breathing effort may result from hypoxia or infection-related metabolic demands. Persistent tachypnea suggests worsening sepsis and requires urgent intervention.
B. Heart rate of 112 beats/minute. A heart rate ≥90 beats/minute is a SIRS criterion, often caused by infection, hypoxia, or systemic inflammation. In pneumonia, tachycardia may result from fever, pain, or compensatory mechanisms due to decreased oxygenation. An elevated heart rate in sepsis may indicate progressing hemodynamic instability.
C. Temperature of 96.1° F (35.6°C). Hypothermia (<96.8°F/36°C) is a SIRS criterion and may indicate severe sepsis or systemic inflammatory response. While fever is a common response, low temperature suggests immune system dysfunction. Hypothermia in sepsis is linked to poor prognosis and increased mortality risk.
D. White blood count of 14,000/mm³ (14 x 10⁹/L). A WBC >12,000/mm³ or <4,000/mm³ meets SIRS criteria and indicates infection-related immune activation. Elevated WBCs suggest an active inflammatory response to pneumonia. A rising WBC count may indicate worsening infection or ineffective immune control.
E. Hemoglobin of 12.8 gram/dL (7.94 mmol/L). Hemoglobin levels within the normal range (12-16 g/dL) do not indicate SIRS or sepsis progression. While anemia can develop in chronic illness or bleeding, this value does not contribute to SIRS classification. Monitoring oxygenation and perfusion is more relevant in pneumonia cases.