A nurse is caring for a client in the emergency department….
Questions
A nurse is cаring fоr а client in the emergency depаrtment. Histоry and Physical 1100: Client presents tо emergency department and states, “I have a terrible headache.” Client reports having a headache for the past three days and the pain is getting worse.. Client reports feeling “feverish” and sensitive to lights. Client has taken ibuprofen for pain and ineffective. Client denies confusion or dizziness, although family members question their confusion yesterday. Past medical history is unremarkable. Nurses' Notes 1100: Nurse to perform assessment on client. Client is squinting eyes to light and nystagmus noted. Rates headache pain as “8” on 0-10 pain scale. Client has nuchal rigidity. Heart regular rhythm and tachycardiac. Lungs sounds are clear to auscultation in all lobes. Client is alert and oriented to person, place and time. 1145: Nurse enters client’s room. Client actively seizing in bed with tonic-clonic characteristics. Placed client on their side. Lorazepam administered, and seizure activity ceased after approximately 1 minute. Provider notified. 1150: Client is lethargic following seizure. Nystagmus noted. Client is tachycardiac. Disoriented to person, place and time. Diagnostics 1130: CT scan: no acute intracranial abnormality, no mass 1230: Lumbar puncture Vital Signs 1100: Temperature 38.3 °C (100.9 °F) Respiratory Rate 19/min Heart Rate 111/min Blood Pressure 129/78 mm Hg 1200: Temperature 38.4 °C (101.1 °F) Respiratory Rate 22/min Heart Rate 115/min Blood Pressure 151/95mm Hg Medication Administration Record 1145: Lorazepam 4 mg IV push Answer all 3 questions below. What potential condition is the client most likely experiencing [condition]? The nurse should take the following actions: [action1] and [action2]? The nurse should monitor [monitor1] and [monitor2]?
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