A nurse assesses a client with a brain tumor. Which newly identified assessment findings should alert the nurse to urgently communicate with the health care provider? (Select all that apply.)
a. Glasgow Coma Scale score of 8
b. Decerebrate posturing
c. Reactive pupils
d. Uninhibited speech
e. Diminished cognition
ANS: A, B, E
The nurse should urgently communicate changes in a client's neurologic status, including a decrease in the Glasgow Coma Scale score, abnormal flexion or extension, changes in cognition or speech, and pinpointed, dilated, and nonreactive pupils.
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