A client has sustained a head injury. What is part of the nursing plan? Select all that apply.

 

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Correct

- Monitor electrolytes

- Evaluate level of consciousness.

- Obtain an EKG.

- Do seizure precautions.

- Regulate hydration according to the intake and output

Rationale

In a head injury, the nurse should evaluate level of consciousness, do strict intake and output measurements, regulating hydration accordingly and do seizure precautions. Hypothermia may need to be a treatment but is not expected spontaneously. An EKG is not usually required.

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