A newly admitted client with increased intracranial pressure caused from a head injury has a Glasgow Coma Scale (GCS)score of 6.Which action by the nurse is the most appropriate?

Question

Quizplus · Accepted Answer

A) The GCS (Glasgow Coma Scale) is a standardized system for assessment of consciousness. A score of 15 indicates full alertness and a score of 8 or less is usually indicative of coma; the lowest possible score is 3. The client's score is low so the nurse should follow the ABCs (airway, breathing, and circulation) of care in this case. Treating the client's pain, taking a history, and assessing the patency of the Foley catheter are done only after the airway is clear and the client is breathing.
B) The GCS (Glasgow Coma Scale) is a standardized system for assessment of consciousness. A score of 15 indicates full alertness and a score of 8 or less is usually indicative of coma; the lowest possible score is 3. The client's score is low so the nurse should follow the ABCs (airway, breathing, and circulation) of care in this case. Treating the client's pain, taking a history, and assessing the patency of the Foley catheter are done only after the airway is clear and the client is breathing.
C) The GCS (Glasgow Coma Scale) is a standardized system for assessment of consciousness. A score of 15 indicates full alertness and a score of 8 or less is usually indicative of coma; the lowest possible score is 3. The client's score is low so the nurse should follow the ABCs (airway, breathing, and circulation) of care in this case. Treating the client's pain, taking a history, and assessing the patency of the Foley catheter are done only after the airway is clear and the client is breathing.
D) The GCS (Glasgow Coma Scale) is a standardized system for assessment of consciousness. A score of 15 indicates full alertness and a score of 8 or less is usually indicative of coma; the lowest possible score is 3. The client's score is low so the nurse should follow the ABCs (airway, breathing, and circulation) of care in this case. Treating the client's pain, taking a history, and assessing the patency of the Foley catheter are done only after the airway is clear and the client is breathing.

A Newly Admitted Client with Increased Intracranial Pressure Caused from a Head