The nurse plans care for a client with a brain tumor who developed a syndrome of inappropriate antidiuretic hormone.
Which interventions should the nurse include in the plan? Select all that apply.

Providing post-mortem care requires knowledge of legal requirements, hospital protocols, and psychosocial support. The nurse must apply principles of cultural sensitivity and respect for the deceased while ensuring that administrative and physical care tasks align with the specific circumstances of death.

Choice A rationale

While a physician or authorized practitioner must pronounce death and sign the certificate, it is not the immediate responsibility of the nurse to ensure the signature is completed before beginning initial post-mortem nursing care.

Choice B rationale

Removing tubes is often prohibited if an autopsy is required, especially in sudden or suspicious deaths. The nurse must first verify the cause of death and institutional policy before disturbing any medical devices or invasive lines.

Choice C rationale

Removing the body immediately is insensitive and may interfere with the grieving process. Families should be given adequate time to spend with the deceased to begin their emotional processing and perform any necessary rituals.

Choice D rationale

Allowing for religious and cultural customs is a core component of holistic nursing care. This respects the dignity of the deceased and supports the family's coping mechanisms during the immediate period following a significant loss.

Choice E rationale

Providing privacy is essential for the family to express grief without observation. This therapeutic environment allows for intimate goodbyes and facilitates the beginning of the mourning process in a respectful and safe hospital or hospice setting.

Monitoring traumatic brain injury involves assessing neurological changes that indicate secondary brain injury. Knowledge of intracranial dynamics and Cushing's triad is essential to identify shifting brain tissue or worsening herniation, which requires immediate medical or surgical intervention to save life.

Choice A rationale

Pupillary changes indicate pressure on the oculomotor nerve but may occur earlier than profound neurological collapse. While important, they are often secondary indicators compared to the global decline seen in mental status and motor function.

Choice B rationale

Fever and elevated blood pressure can occur in brain injury due to hypothalamic dysfunction or sympathetic surges. However, without bradycardia and irregular respirations, they do not definitively indicate immediate, late-stage intracranial pressure emergencies.

Choice C rationale

Headache and nausea are subjective, early signs of increased intracranial pressure. While concerning and requiring monitoring, they do not signify the urgent physiological crisis or neurological deficit represented by a plummeting level of consciousness.

Choice D rationale

A decreased level of consciousness is the most sensitive indicator of neurological deterioration. Coupled with one-sided weakness, it suggests focal deficits or impending herniation, necessitating immediate reporting to prevent permanent brain damage or death.