Assignment task:
A 23-year-old male (pronouns: he/him/his) is brought to the emergency department (ED) by ambulance after falling 15 feet and landing on the flat, grass-covered ground. The client landed on their left side and has lacerations on their left cheek, shoulder, hip, and ankle. The client is strapped to a backboard with a cervical collar in place. Paramedics inform the nurse that the client did not lose consciousness after the fall and has remained alert and oriented to person, place, time, and situation.
Vital signs: BP 122/74, P 64 and regular, R 16 and regular, O2 saturation 99% on room air, and the pupils are equally round and responsive to light and accommodation.
Question: Analyzing Cues
The nurse understands this client is at risk of developing hemiparesis projectile vomiting tachycardia due to acute stress increased ICP systemic hypoxemia.