When providing education to a student nurse about ways to avoid increased intracranial pressure, which of the following will the nurse include in the instructions?(Select All that Apply.)

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 nurse suspects that a client has increasing intracranial pressure. Which of the following diagnostics does the nurse anticipate will be ordered?

A nurse is preparing to administer intravenous mannitol, an osmotic diuretic, to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

A nurse is assessing a client who has ataxia. Which of the following actions should the nurse take to evaluate the client's ability to safely ambulate?

A nurse caring for a client who had a rightsided stroke and is exhibiting homonymous hemlanopsia when eating. Which of the following actions should the nurse take?

A nurse is caring for a client who reports a throbbing headache after a lumbar puncture.  Which of the following actions is most likely to facilitate resolution of the headache? 

A student nurse is asked by the preceptor to identify which of the assigned clients is at the highest risk for stroke. Which of the clients below, when selected by the student nurse, indicate an understanding of the highest risk factor for stroke?

A nurse is assessing a client who has a concussion from a sports injury. Which of the following manifestations should the nurse expect?

You are monitoring the vital signs of an 74yrold man who was admitted for a head injury after he tripped and fell at home. He takes anticoagulants for atrial fibrillation. On arrival his vital signs were stable at BP 150/86, pulse 84, respirations 14/min, but his family reported that he was more restless than usual. He lives alone after his wife passed away. 2 hours after admission, his vital

signs are now BP 166/74, pulse 54, respirations 11/min. He is now quiet and appears sleepy. He is on 2L nasal cannula and has been placed on neutropenic precautions.

A nurse is presenting discharge instructions to a client who has multiple sclerosis (MS). The client reports symptoms of diplopia, dysmetria, and sensory change. Which of the following nursing statements are appropriate?