A week after a client suffered a high thoracic spinal cord injury in a motor vehicle collision, the blood pressure suddenly rises to 196/126 mm Hg. Which physiological sign(s) should the nurse identify that the client is exhibiting autonomic dysreflexia? select all that apply.

The nurse is completing a head to toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the nurse?

An adult client is being admitted to the coronary care unit with a possible myocardial infarction (MI). The client reports feeling like they are going to "pass out." The cardiac monitor displays the rhythm shown. The client's respiratory rate is 12 to 16 breaths/minute and blood pressure is 78/52 mm Hg. The nurse auscultates clear breath sounds bilaterally and the skin is pale and diaphoretic. After administering oxygen, which action should the nurse prepare to perform?

A client with a spinal cord injury has urinary retention related to sensorimotor deficits. Which action should the nurse include in the client's plan of care (РOС)?

The nurse uses the Glasgow coma scale (GCS) to assess a client who has had a stroke. When the nurse calls out the client's name, the client does not open eyes, does not respond to a painful stimulus, and does not make any spoken sound during the assessment. Which statement based on the GCS reflects correct documentation in the electronic medical record of the client's neurological status?

When caring for a client with a cervical spinal cord injury, which intervention is the most important for the nurse to implement?

The nurse recognizes that the client is most at risk for aneurysm

A young man playing football in the park sustains a hard hit and is lying motionless on the ground, while his friends are trying to help him. Which action by his friends warrants immediate intervention by the nurse who was watching from the sidelines?

An unconscious client is demonstrating pulseless ventricular tachycardia (PVT).The nurse checks the client's pulse and begins cardiopulmonary resuscitation (CPR). The defibrillator and crash cart arrive at the bedside and the client is shocked. Which action should the nurse implement next?

After several days of sedation and mechanical ventilation, a client is successfully extubated and is placed on oxygen 40% by face mask. While making rounds, the nurse finds that the client is confused and is attempting to get out of bed. Vital signs are temperature 99.2° F (37.3° C), heart rate 112 beats/minute, respirations 16 breaths/minute, blood pressure 100/70, and oxygen saturation 98%. Which action should the nurse take?