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A client with a T6 spinal cord injury with a Blood pressure is 210/100 mm Hg, and the client reports a pounding headache. What action should the nurse perform first?

A nurse is assessing a client with a suspected spinal cord injury in the emergency department. Which actions should be included in the initial assessment?       Select all that apply

A client with an ischemic stroke is preparing to receive fibrinolytic (tPA) therapy. The nurse notes a current blood pressure of 200/110 mm Hg. Which action should the nurse take first?

The nurse is discussing organ donation with the family of a patient who is near death. Which statement by the nurse is most appropriate to ensure ethical communication?

The nurse is caring for a client with type 1 diabetes with a history of kidney disease. The client blood glucose level is 450 mg/dL., and the healthcare provider ordered a new prescription to begin IV insulin per the protocol scale. Which action should the nurse complete first?

A client with a history of myasthenia gravis is admitted to the emergency department with severe muscle weakness, difficulty breathing, and respiratory distress. What is the priority nursing action?

A client with diabetic ketoacidosis (DKA) was admitted to the intensive care unit 4 hours ago and has two IV lines infusing normal saline solution. The client’s blood glucose level has now decreased to 250 mg/dL. Which intervention should the nurse implement next?

A client with Guillain-Barré Syndrome (GBS) is admitted to the ICU with progressive weakness and numbness in the limbs. Which priority intervention should the nurse anticipate the healthcare provider will prescribe?

A client is brought to the emergency department after falling down a flight of stairs. Assessment reveals:GCS score: 8 (Eye Opening 3, Verbal Response 3, Motor Response 2)Vital signs: BP 145/90 mm Hg, HR 102 bpm, RR 18/min, SpO₂ 94% on room airThe client is somnolent and responding only to verbal and painful stimuli.Given the client’s GCS of 8, what is the priority nursing intervention?

A client with a severe traumatic brain injury (TBI) is transferred to the ICU. A ventriculostomy catheter has been inserted into the right lateral ventricle to continuously monitor intracranial pressure (ICP) and allow for drainage of cerebrospinal fluid (CSF) as needed.Normal ICP = 5–15 mm Hg. Upon admission to the ICU, the nurse notes that the ventriculostomy drainage system is open to drainage and the ICP monitor reads 25 mm Hg. Which action should the nurse take first?