The nurse is caring for a client with a history of headaches. The client has talked to the nurse, smiled at guests, and maintained stable vital signs. The nurse notes the following changes in the client's status. Which assessment finding is criticalto report to the health care provider (HCP)?

Question

Quizplus · Accepted Answer

The level of consciousness is the most important, sensitive, and reliable indicator of the client's neurological status. Changes in the level of consciousness can represent increased intracranial pressure and reduced cerebral blood flow. Changes in vital signs usually do not appear until intracranial pressure has been elevated for some time, or they may be sudden in cases of head trauma. (Option A) The blood pressure is slightly elevated but does not warrant immediate action or signify an emergency situation. (Option C) A poor appetite is not an emergency finding or situation. (Option D) The respiratory rate is slightly low, but if it is not irregular it is not an emergency as a single observation. This finding would warrant further assessment and continued monitoring, but it is not as significant as the change in level of consciousness. Educational objective: A change in level of consciousness for the neurological client should be reported to the HCP. The level of consciousness is the most sensitive and reliable indicator of the client's neurological status.

The Nurse Is Caring for a Client with a History