Medical Surgical Glasgow Coma Scale GCS #5

Question

When caring for a client with a traumatic brain injury with a Glasgow Coma Scale score of 10, what nursing interventions are important to implement? Select all that apply.

Answers

  1. Maintain a patent airway.
    • Rationale:

      This answer is correct because maintaining a patent airway is priority with any traumatic brain injury. Remember to implement the ABCs first.

  2. Address all the client's self-care deficits.
    • Rationale:

      This answer is correct because a GCS score of 10 indicates moderate brain injury, therefore the nurse should address all self-care deficits. The client will probably have no motor responses present.

  3. Maintain a stimulating environment for the client.
    • Rationale:

      This answer is not correct because with any traumatic brain injury, the environment should be quiet with as little stimuli as possible for the client.

  4. Report any changes in the Glasgow Coma Scale score immediately.
    • Rationale:

      This answer is correct because with any change in level of consciousness, the healthcare provider needs to be notified immediately, especially with a decline in the Glasgow Coma Scale score.

  5. Call the client's family every ten minutes with updates on the client's condition.
    • Rationale:

      This answer is not correct because a nurses’ priority is caring for the client and implementing all the interventions needed to improve the client’s condition.

Overview

When caring for a client with a traumatic brain injury with a Glasgow Coma Scale score of 10, the most important nursing interventions to implement include maintaining a client airway; addressing all the client’s self-care deficits; and reporting any changes in the GCS score immediately to the healthcare provider. A GCS of 9-12 indicates a moderate brain injury.

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. 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. When a client’s GCS is 13-15, the client has mild brain injury; a GCS of 9-12 indicates moderate brain injury; and a GCS of 3-8 is severe brain injury.

Test Taking Tip

When determining the best answer options for a question, remember the ABC’s of nursing. Airway and breathing are always first and then circulation.

Video Rationale