Problem:
The nurse is caring for Angela Everheart, a 57-year-old female brought to the emergency department (ED). Review the electronic health record (EHR) and answer the question below.? Nurses' Notes Date/Time Nurse's Note 07/05/20XX 1901 Received Angela Everheart, a 57-year-old female who was brought to the emergency department after experiencing a severe headache that she has had for three days. In the emergency department, she experiences a decreased level of consciousness. She does not open her eyes or respond verbally to any stimuli. Motor response to pain is decerebrate posturing. Pupils are dilated and unequal, with the right pupil being at 7mm, the left being 3mm, and both unresponsive to light. T: 98.4 °F (36.9 °C), BP 180/60, P: 45, R: 8 and irregular, Oxygen Saturation: 84%. Admission weight: 78 kg. Glasgow coma scale: 4 Taking Action Based on the nurse's assessment, which of the following actions should the nurse take immediately? Select all that apply. Given aspirin 650mg by mouth for pain? Request a list of home medications from the family? Encourage incentive spirometer use? Place non-rebreather mask with 15L of oxygen on client? Start intravenous line? Give morphine 4mg intravenously for pain? Notify rapid response team? Cancel lunch tray?