The nurse is caring for a patient with a head injury. Over a time span of 30 minutes, the nurse observes the following vital signs changes: temperature from 97 to 98 F; pulse from 86 to 78 beats/min; respirations from 18 to 14 breaths/min; and
blood pressure from 140/86 to 150/82 . Which action is most important for the nurse to take?
a. Notify the physician immediately.
b. Document the findings.
c. Determine the patient's Glasgow Coma Scale (GCS) score.
d. Observe pupils for size, equality, and reactivity.
Question 2
The nurse is performing a neurologic assessment on a patient. Which action should the nurse take to adequately test the effectiveness for the hypoglossal nerve?
a. Ask the patient to touch the tip of the tongue to each cheek.
b. Check air movement through each nostril separately.
c. Ask the patient to wrinkle the forehead.
d. Ask the patient to shrug the shoulders.
The nurse cares for the postop client in the postanesthesia care unit (PACU).
Head lice
Patient teaching: mouth and pharyngeal assessment
A hearing-impaired patient using an interpreter.
A patient with goiter due to iodine deficiency.
Concepts related to cell injury and aging