A client who experienced a severe head injury is demonstrating a lack of response to painful stimuli, pupils are unequal and fixed, and decorticate posturing. The nurse takes immediate steps, as the client is experiencing:
1. disorientation.
2. early increased intracranial pressure (IICP).
3. a subdural hematoma.
4. signs of late IICP.
Answer: 4
1. Disorientation implies that the client is conscious, which this client is not.
2. Early IICP is characterized by irritability, blurred vision, increased heart rate, and headache.
3. A subdural hematoma has the manifestations of headache, drowsiness, slowed thinking, and confusion, with possible ipsilateral pupil dilation.
4. The client is in late IICP, which is a medical emergency.
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