The multi-organ dysfunction syndrome (MODS), client complains of pain in the distal digits and in the abdomen.  You notice she has multiple petechiae on her skin and that her urine is positive for occult blood.  Select the possible phenomena that might be occurring from the list below:

The nurse is caring for a client in the intensive care unit.  The client is admitted with a traumatic brain injury and has an increased intracranial pressure.  The provider calls the unit and tells the unit secretary to prepare for a lumbar puncture for this patient. The best action by the nurse is to  

A nurse is caring for a client in a coma secondary to brainstem injury.  Nursing interventions in the acute phase are directed toward the goal of:

The nurse is caring for a 52 year old male with Parkinson’s disease which is progressing rapidly. The client has made it clear that his preference is to receive hospice care at home. What interventions should the nurse prioritize in the plan of care? 

The nurse is caring for four patients in a long-term acute care facility. Which of the following clients indicate a readiness to wean from mechanical ventilation?

The client presents in the emergency room with left sided weakness and left facial droop, one blood pressure reading is 240/130.   The priority nursing action for this client is:

A home health nurse instructs the client with heart failure on reasons to call the health care provider. The nurse evaluates the teaching as effective when the client makes the following statement?

A nurse is assessing a patient who is admitted with a pulmonary embolism and is receiving titrated heparin IVPB. The nurse notes the client is scheduled for discharge in two days. Based on this information, the nurse understands it is important to contact the physician for which order? 

The nurse is caring for a client admitted due to a traumatic brain injury requiring a craniotomy to evacuate cerebral bleeding.  The post-operative orders include 3% Normal Saline, Mannitol, and elevation of the head of bed.  The nurse evaluates that the interventions are effective, when the client experiences:

A nurse is administering rivaroxaban to a client with atrial fibrillation.  Which of the following statements by the client indicates teaching was effective?