Practice Question
The nurse cares for a client who sustained a head injury and is experiencing increased intracranial pressure. The Glasgow Coma Scale (GCS) assessment at 0800 was eye-opening to speech, confused, and obeys command. At 1030 the nurse assesses the client, and the GCS is now eye-opening to pain, inappropriate words, and flex to withdraw from pain. Which action by the nurse is priority?
Answer Choices:
Correct Answer:
Call the healthcare provider immediately.
Rationale:
✨ The client’s Glasgow Coma Scale change from responding to speech → responding only to pain indicates a rapid neurological decline.
✨ This worsening level of consciousness suggests increased intracranial pressure, which can quickly progress to brain herniation.
✨ Immediate provider notification is essential so emergency interventions (e.g., airway support, osmotic therapy, repeat imaging) can be initiated.
✨ Rapid response prevents irreversible brain injury, making this action the highest priority.
❌ Incorrect Options Explained
❌ A. Monitor the client – Delays life-saving intervention in a neurologic emergency.
❌ C. Orient the client – Ineffective and inappropriate when the client is deteriorating.
❌ D. Document the finding – Needed, but not the priority when the condition is worsening.
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This question is from NSG 234 EXAM III Version A 2025 which contains 40 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: Examplify Exam(s)
- Domain: Medical-Surgical
- Answer Choices: 4