A nurse is monitoring the vitals of a client who has a traumatic brain injury. Which of the following indicate that the client is in stage 3 of increased Intracranial pressure? Select all that apply
(Select All that Apply.)

The nurse takes report on a client who was admitted with a severe heada

che, nausea, vomiting, photophobia, and a stiff neck. Which of the following is the priority intervention for the nurse to perform?

A nurse is receiving a transfer report for a client who has a head injury. The client has a Glasgow Coma Scale (GCS) score of 3 for eye opening, 5 for best verbal response, and 5 for best motor response. Which of the following is an appropriate conclusion based on this data?

A client reports visual disturbances followed by debilitating pain, nausea, and light sensitivity. When providing education for this client, what can the nurse include in teaching?

Select all that apply (Select All that Apply.)

After explaining the procedure for an electroencephalograph, which of the following statements by the client indicates teaching was not effective?

A nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. When assessing the client, the nurse observes clear fluid draining from the client's nose. Which of the following interventions should the nurse take?

A nurse is preparing to administer Tissue plasminogen activator (tPA). What is the likely reason the client will receive this treatment?

A client arrived by EMS after a bar fight. He is disoriented with a Glasgow coma scale of 10.

 What additional finding indicates that he has suffered a basilar skull fracture? 

A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse Include? (Select all that apply.)

A client arrives to the emergency department after a motor vehicle accident. The nurse records the following Glasgow Coma scores: E3, V2, M1. What is the best first action for the nurse to take.

The nurse caring for a client with a brain tumor will monitor for which of the following early signs of increased intracranial pressure?