The Nurse Is Caring for a Client with a Diagnosed

Multiple Choice

The nurse is caring for a client with a diagnosed closed head injury that requires intracranial pressure monitoring.Which signs/symptoms indicate that the client's intracranial pressure is rising? Select all that apply.

A) The nurse notes "Doll's eyes" when assessing the client's pupils.
B) The nurse documents eupnea in respect to respiratory effort.
C) The nurse finds that all extremities are flaccid.
D) The nurse notes that blood pressure is stable.
E) The nurse documents that the client is in a comatose state.