An adult client is transported via ambulance to the emergency department (ED) following a motor vehicle collision. On arrival the client reports experiencing severe upper back pain. The vital signs are a temperature of 98.6° F (37° C) orally, heart rate 145 beats/minute, respirations 26 breaths/minute, and blood pressure 70/40 mm Hg. Which change in assessment findings indicate that the client's condition is deteriorating?

After two hours post coronary artery bypass surgery the client experienced a central venous pressure increasing from 13 mm Hg to 17 mm Hg within a half hour. The systolic blood pressure dropped to 90 mm Hg on inspiration and rose to 110 mm Hg on expiration. Heart sounds are distant upon auscultation, and decreased electrocardiogram (ECG) waveform amplitudes are assessed. Which is the cause of these clinical manifestations?

When caring for a client with a traumatic brain injury (TBI) who had a craniotomy for increased intracranial pressure (ICP), the nurse assesses the client using the Glasgow coma scale (GCS) every two hours. For the past 8 hours the client's GCS score has been 14. Which does this GCS finding indicate about this client?

Patient Data

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.

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?

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?

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 is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. Which is the priority nursing intervention based on the client's current GCS?

Based on this strip, which is the correct interpretation of this rhythm?