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The nurse is caring for a client with a diagnosed closed head injury that requires intracranial ...

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The nurse is caring for a client with a diagnosed closed head injury that requires intracranial ...

The nurse is caring for a client with a diagnosed closed head injury that requires intracranial pressure monitoring. Which signs/symptoms indicate that the client's intracranial pressure is rising? Select all that apply.

▸ The nurse notes "Doll's eyes" when assessing the client's pupils.

▸ The nurse documents eupnea in respect to respiratory effort.

▸ The nurse finds that all extremities are flaccid.

▸ The nurse notes that blood pressure is stable.

▸ The nurse documents that the client is in a comatose state.

Textbook

Clinical Nursing Skills: A Concept-Based Approach

Edition: 3^rd

Author: Callahan

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