The Intensive Care Unit Nurse Is Preparing to Assess the Level

The intensive care unit nurse is preparing to assess the level of consciousness of a client who is intubated and has both hands restrained to prevent the client from pulling out the endotracheal tube.The client's injury occurred due to a stabbing incident that ultimately caused the client to fall and hit his head.Which item related to the client will cause the nurse to report an incomplete Glasgow Coma Score (GCS) ?

A) The client is intubated.
B) The client's hands are restrained.
C) The client was stabbed.
D) The client fell and hit his head.