A Critical Care Nurse Is Caring for a Client with a Neurologic

question 4

Multiple Choice

A critical care nurse is caring for a client with a neurologic disorder. The nurse regularly records the temperature and blood pressure of the client and has not observed any change in the client's vital signs for some days. However, on a particular day, the nurse observes a change in the vital signs of the client. What would be a priority action for the nurse to take when a change in the vital signs is observed?

• A) Inform the physician immediately.
• B) Note the change and inform the physician at the next occurrence about the change.
• C) Provide measures to normalize vital signs.
• D) Assess the level of consciousness (LOC) and the pupil response of the client.

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Definitions:

Fixed Interval

In operant conditioning, a schedule of reinforcement where the first response is rewarded only after a specified amount of time has elapsed.

Partial Reinforcement Effect

The typical outcome of a variable ratio of reinforcement in which a slow rate of initial learning is coupled with resistance to extinction.

Continuous Reinforcement

A learning process in which a behavior is rewarded every time it is exhibited, leading to rapid learning.

Extinction Resistance

The phenomenon where a learned behavior persists even after it is no longer reinforced, indicating a resistance to extinction.