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ogf78 ogf78
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The nurse is caring for an older adult client who sustained a closed head injury approximately 4 hours ago. At the time of the injury, the client denied any pain or other symptoms. Which statement by the client would cause the MOST concern to the nurse?

▸ "Who are you? Why do you keep asking me my name?"

▸ "I wish the nurses would stop coming in and shining a light in my eyes. It's annoying."

▸ "This is so silly. I really don't see why all of this is necessary."

▸ "Please let me go home. I will come back if I have any problems."
Textbook 
Clinical Nursing Skills: A Concept-Based Approach

Clinical Nursing Skills: A Concept-Based Approach


Edition: 3rd
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deathnature9deathnature9
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"Who are you? Why do you keep asking me my name?"

A very early sign of increased ICP is a slight change in level of consciousness. The client does not appear to recognize the nurse or understand why the assessments are being done.
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ogf78
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