A nurse is providing teaching to a client about an upcoming hysterosalpingography. Which of the following statements should the nurse include?

A. Prepare the client for surgery: Surgical intervention is required to repair the evisceration, but the immediate priority is to protect the exposed organs from contamination and desiccation by covering them with a sterile saline-moistened dressing.

B. Cover the protrusion with a dressing soaked in 0.9% sodium chloride: This is the priority action to prevent the exposed organs from drying out and reduce the risk of infection. Sterile saline keeps the tissue moist, which is essential for preserving organ viability until surgical repair can be performed.

C. Obtain the client's vital signs every 5 min until the provider arrives: Monitoring vital signs is important to assess for shock, but it is not the first priority. Protecting the exposed abdominal contents takes precedence before initiating continuous monitoring.

D. Raise the head of the bed to 20°: The client should be placed in a low Fowler’s position with knees slightly flexed to reduce abdominal tension, but the most immediate action is to cover the exposed organs with a sterile saline-moistened dressing.

A. Decorticate posturing: This is a late sign of increased intracranial pressure, indicating severe brain dysfunction and potential herniation. Early signs of increased ICP typically involve subtle neurological changes such as restlessness, confusion, or irritability before progressing to abnormal posturing.

B. Restlessness: An early sign of increased ICP, restlessness occurs due to decreased cerebral perfusion and oxygenation, leading to subtle changes in mental status. Clients may also exhibit irritability, confusion, or difficulty following commands before more severe symptoms develop.

C. Papilledema: Swelling of the optic disc, or papilledema, is a later sign of increased ICP and occurs due to prolonged pressure on the optic nerve. It is typically detected on an ophthalmic exam rather than presenting as an early symptom.

D. Projectile vomiting: Vomiting without nausea is a later sign of increased ICP, often associated with brainstem involvement. Early manifestations tend to involve altered mental status before progressing to severe symptoms such as vomiting or posturing.