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The nurse is caring for a client with multiple sclerosis. The client has a stage II pressure ulcer on the sacrum. Which intervention will the nurse delegate to the unlicensed assistive personnel (UAP)?

The nurse is observing a client with cerebral edema for evidence of increasing intracranial pressure (IICP). Monitoring the blood pressure for a widening pulse pressure. The current blood pressure is 170/80 mmHg. What is the client’s pulse pressure? (Answer in whole number) _______

In relationship to activities of daily living, what should the nurse include in the teaching plan for the client with multiple sclerosis? 

A nurse is caring for a 20-year-old male client who has a fever and reports severe headache.Vital Signs at 0800Temperature 38.9° C (102° F); TympanicApical pulse 118/min; strong and regularRespirations 20/min; even and unlabored Blood pressure 114/78 mm Hg Oxygen saturation 97% on room airNurses Notes0800:Client reports missing classes at a local community college the last two days due to fever and headache. Rates pain with headache as a 9 on a scale of 0 to 10. Verbalizes that headache was not relieved by acetaminophen or ibuprofen taken at home. Client awake, alert, and oriented to person, place, and time. Pupils equal, round, and reactive to light. Temperature elevated.  Skin warm and dry, face flushed.  Petechiae noted on trunk.  Reports nausea and vomiting frequent for the last 24 hr. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present.  Nuchal rigidity noted.  Brudzinski’s sign positive. Respirations easy and unlabored.  Lungs clear to auscultation.   The nurse should address the client’s ___________ followed by the client’s ____________.

A nurse is caring for a 20-year-old male client who has a fever and reports severe headache.Vital Signs at 0800Temperature 38.9° C (102° F); TympanicApical pulse 118/min; strong and regularRespirations 20/min; even and unlabored Blood pressure 114/78 mm Hg Oxygen saturation 97% on room airNurses Notes0800:Client reports missing classes at a local community college the last two days due to fever and headache. Rates pain with headache as a 9 on a scale of 0 to 10. Verbalizes that headache was not relieved by acetaminophen or ibuprofen taken at home. Client awake, alert, and oriented to person, place, and time. Pupils equal, round, and reactive to light. Temperature elevated.  Skin warm and dry, face flushed.  Petechiae noted on trunk.  Reports nausea and vomiting frequent for the last 24 hr. Bowel sounds positive x 4 quadrants. Abdomen soft and nontender to light palpation. Photophobia present.  Nuchal rigidity noted.  Brudzinski’s sign positive. Respirations easy and unlabored.  Lungs clear to auscultation.   The nurse is caring for a 20-year-old male client. Select the findings below that would require follow up? Select all that apply.

The client has been diagnosed with Guillain Barre´ Syndrome. What assessment would indicate the client is having clinical manifestations of this disease process?

Prior to the patients scheduled lumbar puncture, what is the priority nursing action for this client?

The nurse observes that the client has no motor function, is limp and lacks motor tone. What documentation is most appropriate when recording the client’s posture?

Which assessment data would best accurately describe a patient with increased intercranial pressure (IICP)?

What assessment information is appropriate to document when recording stimulation of the parasympathetic nervous system?