The nurse is providing care for a client with a head injury and wants to decrease the client's risk for developing increased intracranial pressure (IICP).Which assessment data indicates that the nurse is successful? Select all that apply.

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A) Assessment areas include LOC; behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. Adequate air exchange is needed to keep oxygen and carbon dioxide levels within normal ranges and maintenance of acid-base balance is critical to reduce the risk of hypoxemia and IICP. An oxygen saturation level of 93% is within normal limits. A sluggish response to verbal stimuli could indicate increasing ICP.
B) Assessment areas include LOC; behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. Adequate air exchange is needed to keep oxygen and carbon dioxide levels within normal ranges and maintenance of acid-base balance is critical to reduce the risk of hypoxemia and IICP. An oxygen saturation level of 93% is within normal limits. A sluggish response to verbal stimuli could indicate increasing ICP.
C) Assessment areas include LOC; behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. Adequate air exchange is needed to keep oxygen and carbon dioxide levels within normal ranges and maintenance of acid-base balance is critical to reduce the risk of hypoxemia and IICP. An oxygen saturation level of 93% is within normal limits. A sluggish response to verbal stimuli could indicate increasing ICP.
D) Assessment areas include LOC; behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. Adequate air exchange is needed to keep oxygen and carbon dioxide levels within normal ranges and maintenance of acid-base balance is critical to reduce the risk of hypoxemia and IICP. An oxygen saturation level of 93% is within normal limits. A sluggish response to verbal stimuli could indicate increasing ICP.
E) Assessment areas include LOC; behavior; motor/sensory functions; pupillary size and reaction to light; and vital signs, including temperature. An elevated temperature with increased oxygen consumption further increases ICP. Pressure on the brainstem may compromise the function of protective mechanisms such as the gag reflex. Pupillary responses mirror the status of the midbrain and pons. Adequate air exchange is needed to keep oxygen and carbon dioxide levels within normal ranges and maintenance of acid-base balance is critical to reduce the risk of hypoxemia and IICP. An oxygen saturation level of 93% is within normal limits. A sluggish response to verbal stimuli could indicate increasing ICP.

The Nurse Is Providing Care for a Client with a Head