The Nurse Is Caring for a Client with a Diagnosed

question 9

Multiple Choice

The nurse is caring for a client with a diagnosed closed head injury that requires intracranial pressure monitoring.Which signs/symptoms indicate that the client's intracranial pressure is rising? Select all that apply.

• A)The nurse notes "Doll's eyes" when assessing the client's pupils.
• B)The nurse documents eupnea in respect to respiratory effort.
• C)The nurse finds that all extremities are flaccid.
• D)The nurse notes that blood pressure is stable.
• E)The nurse documents that the client is in a comatose state.

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Definitions:

Ineffective Sexuality Pattern

A nursing diagnosis referring to a person's expressed concern regarding their sexuality and sexual relationships.

Values Conflicts

Discrepancies between the principles or beliefs of individuals or groups that can lead to disagreements or disputes.

Sexual Orientation

An enduring pattern of romantic or sexual attraction (or lack thereof) to persons of the opposite sex, same sex, both sexes, or more than one gender.

Sexual Dysfunction

A term used to describe any problems during any phase of the sexual response cycle that prevent the individual or couple from experiencing satisfaction from the sexual activity.