A nurse on the medical-surgical unit is caring for a 47 year…

A nurse on the medical-surgical unit is caring for a 47 year old client in shock and assesses the following:Respiratory rate: 10 breaths/minPulse: 136 beats/minBlood pressure: 92/78 mm HgLevel of consciousness: responds to voiceTemperature: 101.5° F (38.5° C)Urine output for the last 2 hours: 40 mL/hr.What action by the nurse is best?

The nurse is caring for a 68-year-old male client, Mr. Steve…

The nurse is caring for a 68-year-old male client, Mr. Stevens, who recently experienced a hemorrhagic stroke. He has a history of hypertension and atrial fibrillation. Which of the following assessment findings is the earliest indicator of increasing intracranial pressure (ICP) in this client?