The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

Question

A) The client has periorbital edema and ecchymosis.
B) The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.
C) The client's level of consciousness has improved.
D) The client prefers to rest in the semi-Fowler's position.

Answer 1

B
Feedback:
The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.