A patient is brought to the emergency department by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

A nurse is doing a postop assessment on an infant who has just had a ventroperitoneal shunt placed for hydrocephalus. Which assessment would indicate a malfunction in the shunt?

The elderly client is admitted to the intensive care department diagnosed with severe hyperosmolar hyperglycemic syndrome (HHS). Which collaborative intervention should the nurse include in the plan of care first?

The nurse is teaching the client with myasthenia gravis about the prevention of myasthenic and cholinergic crises. The nurse tells the client that this is most effectively done by:

The nurse is prioritizing care for this shift, which client should the nurse see first?

The client is admitted to the intensive care department (ICD) experiencing status epilepticus. Which collaborative intervention should the nurse anticipate?

A patient arrives to the emergency department and is unable to give you a health history due to altered mental status. The family reports the patient has gained over 10 lbs in 1 week and says it is mainly “water” weight. In addition, they report the patient hasn’t been able to urinate or eat within the past week as well and was recently diagnosed with small cell lung cancer. On assessment, you note the patient’s HR is 115 and BP 180/92. Patient sodium level is 90 (normal sodium 135-145). Which of the following conditions do you suspect the patient is most likely presenting with?

A nurse is caring for a patient who has been prescribed mannitol. Which of the following assessments is most important for the nurse to perform to monitor for potential adverse effects of this medication?

When assessing the body functions of a patient with increased intracranial pressure (ICP), what should the nurse assess first?

A 23-year-old male with a history of type I diabetes presented to the emergency department due to a change in mental status.   Nurses’ Notes   1200 23-year-old male with a history of diabetes type I brought to the emergency department by spouse for changes in mental status from his baseline. The client’s wife reports that he woke at 0600 to complete his morning routine. At approximately 1100 he became unaware of his surroundings and began sweating profusely and slurring his words. Breath sounds are clear but noted with a fruity citrus odor and deep rapid respiration’s. Sinus tachycardia per cardiac monitor. He is awake and alert, pupils equal and reactive to light. Vital Signs   Time 1200   Temp 99.5° F (37.5 °C)   P 118   RR 32   B/P 89/52   Pulse oximeter 89% on RA   Medications   Humalog insulin subcut sliding scale with meals   Lantus 10units QHS                 Which 4 findings are most significant?