ATI Targeted Medical Surgical Neurosensory and Musculoskeletal questions and answers 100% verified

ATI Targeted Medical Surgical Neurosensory and Musculoskeletal questions and answers 100% verified. A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following intervention is the nurse's priority? A. Maintain a PaCO2 of approx. 35 mmHg B. Provide small doses of fentanyl via bolus for pain management C. Measure body temperature every 1-2hr - correct answers.A. Maintain a PaCO2 of approx. 35 mmHg The greatest risk to this client is injury from increased intracranial pressure. Therefore, the nurse's priority action is to maintain the PaCO2 at approximately 35 mm Hg to prevent hypercarbia and subsequent vasodilation effects that lead to increase in intracranial pressure. A nurse is caring for a client who has a retinal detachment. which of the following findings should the nurse expect? A. Photophobia B. Complete vision loss C. Flashes of bright light D. Cloudiness of the lends - correct answers.C. Flashes of bright light The nurse should expect a client who has a retinal detachment to see flashes of bright light or floating dark spots in the affected eye as the retinal layers separate. Photophobia - The nurse should expect photophobia in a client who has a migraine headache. Complete vision loss -The nurse should expect a client who has a retinal detachment to have some visual field loss in the area of the detachment, but complete vision loss is not an expected finding. Cloudiness of the lens- The nurse should expect a client who has cataracts to experience cloudiness of the lens A nurse is caring for a client who has a spastic bladder following a spinal cord injury. Which of the following actions should the nurse take to help stimulate micturition? A. Encourage the clie