A nurse is assessing a client with suspected increased intracranial pressure following a traumatic brain injury. The nurse monitors for the development of Cushing’s triad. Which assessment findings indicate this life-threatening condition? Select all that apply. 

A nurse is working in the emergency department during a busy shift. Several clients arrive at the same time with varying conditions, including a minor laceration, chest pain, difficulty breathing, and a broken arm. What is the primary purpose of triage in this situation?

A client is admitted to the burn unit with full-thickness burns covering the trunk and head. The client is in the first few hours post-injury. During the emergent (resuscitative) phase of burn management, which goal should the nurse prioritize?

A client with community-acquired pneumonia is becoming increasingly lethargic and confused. Vital signs are:  HR: 124 bpm with frequent PVCs BP: 78/50 RR: 28/min with shallow respirations Urine output: 10 ml over the past hour Cool clammy skin with delayed capillary refill.    The nurse recognizes these findings as most consistent with which stage of shock?

The nurse is working on a burn unit and an acutely ill client is exhibiting signs and symptoms of third spacing. Based on this change in status, the nurse should expect the client to exhibit signs and symptoms of which imbalance?  

Cheating and plagiarism is taking another person’s work as your own in an exam. As an accounting/business student, how would you deal with unethical behaviour? If you are aware of another student engaged in this type of behaviour, would you report their violation of academic integrity?

The nurse is providing health promotion teaching to a patient with multiple sclerosis (MS) to help prevent exacerbations. Which statements should the nurse include? (Select all that apply)

A nurse is reviewing ECG rhythm strips for four clients on a telemetry unit. Which rhythm requires immediate intervention?   Client A Client B Client C Client D

A 58-year-old client with a history of coronary artery disease is admitted to the emergency department with complaints of palpitations, dizziness, and chest pain. The ECG shows a wide, regular tachycardia with a rate of 180 bpm, and the patient appears hypotensive. The healthcare provider suspects ventricular tachycardia (VT). Which intervention should the nurse prioritize?

A 32-year-old client is brought to the emergency department after a motor vehicle crash. The primary survey has been completed, and the client’s airway, breathing, and circulation are stable. During the secondary survey, the client reports abdominal pain and numbness in the left leg. The nurse notes bruising across the lower abdomen and a deformed left femur. Which action should the nurse take first?