The nurse is caring for a client diagnosed with a glioblastoma who has just returned from surgery to remove as much of the tumor as possible
When gathering data on this client, the nurse's priority will be to monitor which of the following? Select all that apply. Standard Text: Select all that apply. 1. Ability to respond to commands and bilateral muscle strength
2. Ability to speak, write, and recognize objects
3. Orientation to time, place, and person
4. Pupil response to light
5. Coping mechanism
1,2,3,4
Rationale: Location of the tumor, and areas of potential damage within the brain, will determine specific assessment requirements, but in general, the nurse will monitor the client's ability to respond to commands (touch your nose with your left hand, blink your eyes, etc.); bilateral muscle strength; ability to speak, write, and recognize objects; pupil response; and orientation. Any alteration in neurological activity should be reported to the nursing supervisor or surgeon immediately. Coping mechanisms are not a priority, and will not be evaluated until the client has time to recover from the immediate postoperative period.
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