A client is being cared for after a traumatic brain injury. During an initial assessment, the nurse performs the Glasgow Coma Scale and gives the client a score of 8. Which of the following responses from the nurse is appropriate to manage the client’s respiratory rate?
A nurse is completing a neurological assessment in a client with a back injury. Which of the following steps would be part of a test of motor function in this client? Select all that apply.
An adult client presents to the emergency department with scabs all over their skin and missing teeth. The client has dilated pupils and is sweating despite being afebrile. Which substance does the nurse correctly suspect that this client is using?
A client has presented to the emergency department full of energy and unable to sit still. The nurse notes dilated pupils. Vital signs are normal except for tachycardia is present. These assessment findings are consistent with abuse of which substance?
A nurse is performing a neurological exam on a client who is in the healthcare clinic. Which of the following is a component of assessing deep tendon reflexes? Select all that apply.
The nurse notes that a client in the emergency department waiting room is nodding off. The nurse takes their vital signs which are within normal limits. The nurse notes bilateral pinpoint pupils. Which substance does the nurse suspect is being abused by this client?
A client is preparing to undergo a craniotomy for treatment of a brain bleed. The nurse performs the pre-operative assessment and includes the Glasgow Coma Scale (GCS). The client is intubated, sedated, and has an endotracheal tube in place for airway management. Which intervention should the nurse utilize to perform the pre-operative assessment?
