A 67-year-old client is admitted following a head injury. The client is increasingly restless, reporting a headache rated 7 out of 10, and has become less responsive to questions over the last hour. Pupils are equal but sluggishly reactive. Vital signs: BP 148/86 mm Hg, HR 62 bpm, RR 14, SpO₂ 96% on room air. The client is lying in a supine position with the head of the bed at 15 degrees. No vomiting reported.
The nurse is reviewing the client’s findings and considering their acute condition.
Choose the most appropriate options to complete the sentence by selecting from the lists of options provided.
The nurse suspects that the client is experiencing [delirium / increased intracranial pressure / hypoglycemia / seizure activity] , which places them at risk for [peripheral neuropathy / disrupted fluid balance / respiratory depression / reduced cerebral perfusion] .
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