During routine suctioning of a client with an endotracheal tube, the patient becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?

Choice A reason:

Assessing the client's serum sodium level is the priority action. The symptoms of generalized edema, decreased urine output, acute confusion, and muscle weakness are suggestive of possible hyponatremia or other electrolyte imbalances, which can be critical in the postoperative period following a craniotomy. Checking the serum sodium level will provide essential information to guide further treatment.

Choice B reason:

While continuing to monitor the client's urinary output is important, it does not address the immediate need to diagnose and correct a potential electrolyte imbalance. The nurse needs to take action to determine the underlying cause of the patient's symptoms.

Choice C reason:

Increasing the rate of the IV infusion could potentially worsen the patient's condition, especially if the symptoms are related to fluid overload or electrolyte imbalance. This action should only be taken based on specific clinical indications and after appropriate assessments.

Choice D reason:

Administering desmopressin IV per protocol is not appropriate as the first action without confirming the underlying cause of the symptoms. Desmopressin is used for specific conditions such as diabetes insipidus, and its administration should be based on a confirmed diagnosis.

Choice A reason:

Assessing the level of consciousness is the most important nursing assessment for detecting early signs of a declining condition in a patient with a severe concussion. Changes in consciousness can indicate worsening brain injury or increased intracranial pressure, and prompt recognition is crucial for timely intervention.

Choice B reason:

A focal neurological exam is important but is more specific to identifying localized neurological deficits rather than detecting general deterioration. It is essential but secondary to monitoring the overall level of consciousness.

Choice C reason:

Body posturing can indicate severe brain injury or increased intracranial pressure, but it typically occurs later in the course of deterioration. Early changes in the level of consciousness are more sensitive indicators of a declining condition.

Choice D reason:

Vital signs are important to monitor, but changes in vital signs can occur later in the progression of a declining neurological status. Early detection of changes in the level of consciousness allows for more timely intervention.