Med Surg 1 Final Exam Latest Update

Med Surg 1 Final Exam Latest Update A nurse is caring for a client who is postprocedure following lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select all that apply) a.) Use the Glasgow Coma Scale when assessing the client b.) Assist the client to a supine position c.) Administer an opioid medications d.) Encourgae the client to increase fluid intake e.) Instruct the client to perform deep breathing and coughing exercises b,c,d A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter (ventriculostomy) for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? a.) Headache b.) Infection c.) Aphasia d.) Hypertension b A nurse is assessing a client for changes in the level of consciousness using the Glasgow Coma Scale (GCS). The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following GCS scores should the nurse document? a.) E2+V3+M5 = 10 b.) E3+V4+M4= 11 c.) E4+V5+M6= 15 d.) E2+V2+M4= 8 b