The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?

Prepare to give phenytoin IV as prescribed.

Perform a substernal rub to evoke a response to pain.

Promptly notify the healthcare provider (HCP) of the GCS score.

Continue monitoring the client's GCS score every 2 hours.

Answer and Explanation

The Correct Answer is D

A. Prepare to give phenytoin IV as prescribed. Phenytoin is used for seizure prophylaxis in clients with moderate to severe head injuries (GCS ≤ 8–10). A GCS score of 14 indicates mild head injury, and prophylactic anticonvulsants may not be necessary unless ordered for specific risk factors.
B. Perform a substernal rub to evoke a response to pain. A substernal rub (painful stimulus) is used to assess response in unconscious or unresponsive clients (GCS ≤ 8). With a GCS of 14, the client is alert or nearly fully conscious, making a painful stimulus unnecessary and inappropriate.
C. Promptly notify the healthcare provider (HCP) of the GCS score. A GCS of 14 is not a critical or emergency finding, as it indicates mild neurological impairment. While the HCP should be updated on significant changes, routine monitoring is sufficient unless deterioration occurs.
D. Continue monitoring the client's GCS score every 2 hours. Frequent neurological assessments are crucial in head injury management to detect worsening conditions like increasing intracranial pressure (ICP) or cerebral edema. Monitoring the GCS every 2 hours ensures timely intervention if the client’s condition changes.

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Correct Answer is D

Explanation

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

A. Observe vital signs sequences as a way of assessing for Cushing's triad. B. Evaluate hourly urinary output. C. Monitor arterial blood pressure. D. Assess intracranial pressure following intracranial transducer placement.

Correct Answer is D

Explanation

A. Observe vital signs sequences as a way of assessing for Cushing's triad. Cushing’s triad (hypertension with widened pulse pressure, bradycardia, and irregular respirations) is a late sign of increased intracranial pressure (ICP). While monitoring for it is important, early recognition and direct ICP monitoring are more effective in preventing deterioration.
B. Evaluate hourly urinary output. Mannitol is an osmotic diuretic that can cause significant diuresis, requiring close monitoring of urine output to prevent dehydration and electrolyte imbalances. However, assessing ICP is the priority because increased ICP can cause brain herniation, which is life-threatening.
C. Monitor arterial blood pressure. Dopamine is a vasopressor used to maintain cerebral perfusion pressure (CPP), which is crucial in head injury management. While blood pressure monitoring is essential, directly assessing ICP ensures that treatment is effective in preventing secondary brain injury.
D. Assess intracranial pressure following intracranial transducer placement. The highest priority is monitoring ICP immediately after placement to detect dangerous elevations that could lead to herniation. The intraventricular catheter provides real-time pressure readings, guiding interventions like mannitol administration and blood pressure control to optimize cerebral perfusion and prevent worsening neurological damage.

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The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?

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