A nurse is caring for a patient who has cirrhosis of the liver.
The patient’s vital signs are as follows: Heart rate 101/min, Temperature 36 C (96.9 F), Respiratory rate 24/min, Blood pressure 82/58 mm Hg, Oxygen saturation 92%. Which of the following assessment findings require immediate follow-up? Select all that apply.

Choice A rationale

Hyperventilation is a potential treatment for brain herniation. Hyperventilation causes a decrease in carbon dioxide levels in the blood, leading to vasoconstriction of the cerebral blood vessels. This reduces cerebral blood flow and decreases intracranial pressure, which can help in the management of brain herniation.

Choice B rationale

Decreasing sedation is not typically a treatment for brain herniation. Sedation can be used in the management of increased intracranial pressure, but it is not a direct treatment for brain herniation.

Choice C rationale

Reducing the temperature in the room is not a direct treatment for brain herniation. While temperature control is important in the overall management of a patient with brain injury, it does not directly treat brain herniation.

Choice D rationale

Lowering blood pressure is not a direct treatment for brain herniation. While maintaining optimal blood pressure is important in the management of brain injury, aggressive lowering of blood pressure is not typically done as it could compromise cerebral perfusion.

Choice A rationale

Intussusception is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This “telescoping” often blocks food or fluid from passing through.

Intussusception also cuts off the blood supply to the part of the intestine that’s affected. It can lead to a tear in the bowel (perforation), infection and death of bowel tissue.

Choice B rationale

Wilms’ tumor is a rare kidney cancer that primarily affects children. Also known as nephroblastoma, Wilms’ tumor is the most common cancer of the kidneys in children. Wilms’ tumor most often affects children ages 3 to 4 and becomes much less common after age 52.

Choice C rationale

Pyloric stenosis is a condition that affects infants between birth and 6 months of age and causes forceful vomiting that can lead to dehydration. It’s the second most common reason why newborns have surgery. Pyloric stenosis can be fixed with a surgical procedure called pyloromyotomy.

Choice D rationale

Nephrotic syndrome is a kidney disorder that causes your body to excrete too much protein in your urine. Nephrotic syndrome is usually caused by damage to the clusters of small blood vessels in your kidneys that filter waste and excess water from your blood.