The nurse finds an adult client who has had a sudden decrease in the Glasgow Coma Scale from 13 to 11. The priority action for the nurse is to:

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The sudden decrease in Glasgow Coma Scale indicates a decline in neurological status, which could be life-threatening. Therefore, the priority action for the nurse is to summon the Medical Emergency Team (MET) to ensure prompt and appropriate intervention. Waiting and re-assessing the client or checking for an advanced health directive can be done after the client receives immediate attention from the MET. Asking a colleague to check the assessment may also be helpful, but it should not delay calling the rapid response team.

The Nurse Finds an Adult Client Who Has Had a Sudden