An elderly client is admitted after sustaining a closed head injury in an accident. The client is alert and oriented but very lethargic, and there is clear fluid draining from the nose. Develop a plan of care to prioritize the client’s safety and minimize the risk of complications. Select the nursing actions to include in the plan of care: Select all that apply.

The nurse is assessing a patient who sustained a traumatic brain injury. Using the Glasgow Coma Scale (GCS), match each observed patient response with the appropriate GCS component and score.

The nurse is teaching an adolescent client newly diagnosed with type 1 diabetes mellitus about recognizing and preventing diabetic ketoacidosis (DKA). Which statement by the client demonstrates an understanding of the teaching?

The patient you are caring for is hyperventilating from anxiety and abdominal pain. Which assessment findings should the nurse attribute to respiratory alkalosis? (Select all that apply.)

The nurse is reviewing a rhythm strip for a patient who recently experienced a mild stroke. The strip shows no visible P waves, an irregularly irregular rhythm, and a QRS duration of 0.12 seconds. How should the nurse explain this rhythm to the patient?

A patient with a stroke experiences right-sided arm and leg paralysis and facial drooping on the right side. When admitting the patient, which clinical manifestation will the nurse expect to find?

A 45-year-old patient has been receiving total parenteral nutrition (TPN) for 5 days due to severe malabsorption. The nurse is educating the patient about the therapy and potential complications. Which statement by the patient indicates a correct understanding of TPN therapy? 

The nurse is caring for a 73-year-old man with cirrhosis. Which assessment finding indicates the greatest risk for the patient’s safety and requires immediate intervention?

A patient with diabetes insipidus is prescribed desmopressin (DDAVP). Which statement by the nurse best explains the purpose of this medication?

A patient with massive trauma and suspected spinal cord injury is admitted to the emergency department. Which assessment finding should the nurse prioritize to guide the management of neurogenic shock?