Medical Surgical Glasgow Coma Scale GCS #4

Question

The nurse is caring for a client who was admitted 8 hours ago for a traumatic brain injury. The client’s Glasgow Coma Scale score was 15 upon arrival, but now the client’s GCS score is 6. What is the priority intervention?

Answers

  1. Reposition the client and lower the head of the bed.
    • Rationale:

      This answer is not correct because repositioning the client and lowering the head of the bed could cause increased intracranial pressure and the Glasgow Coma Scale score to worsen.

  2. Call the Medical Response Team to code the client.
    • Rationale:

      This answer is not correct because the client has not stopped breathing and does still have a pulse. The Medical Response Team should be alerted to code the client if the client has stopped breathing and/or has no pulses.

  3. Increase the client's oxygen to 4 Liters/minute.
    • Rationale:

      This answer is not correct because the scenario does not mention that the client currently is wearing oxygen.

  4. Notify the healthcare provider immediately.
    • Rationale:

      This answer is correct because if a client arrives with a GCS score of 15 and then declines to a GCS score of 8, this is a medical emergency and the healthcare provider must be notified immediately and the client sent to the intensive care unit.

Overview

The total Glasgow coma scale (GCS) highest score is 15, which is considered normal brain activity. If the client’s GCS is less than 8, the client is considered neurologically unstable, a medical emergency, and will be placed in the intensive care unit.

Explanation

Learning Outcomes

The Glasgow coma scale is a 3-15 point scale which helps to determine level of consciousness or neurological status for the client with a traumatic brain injury. If a client arrives with a GCS score of 15 and then declines to a GCS score of 8, this is a medical emergency and the healthcare provider must be notified immediately and the client sent to the intensive care unit.

Test Taking Tip

When caring for any client, level of consciousness is important to determine arousability and responsiveness to the environment. Through assessing level of consciousness, one can determine how neurologically intact or if the client has a deficit with traumatic brain injuries.

Video Rationale