The Nurse Is Providing Care for a Client with a Head

Multiple Choice

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.

A) Body temperature elevated 1 degree in 4 hours
B) Absent gag reflex
C) Pupils equal and reactive to light
D) Oxygen saturation 93% via pulse oximetry
E) Sluggish response to verbal stimuli