An emergency department nurse receives a report that an incoming client has a Glascow Coma Scale (GCS) score of 8. The nurse prepares to implement which of the following?

Question

1. Treat the client's pain
2. Assess airway, breathing, and circulation
3. Get a complete history from the client
4. Triage with the other emergency department clients

Answer 1

2. Assess airway, breathing, and circulation

Rationale:
The GCS (Glascow 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. A comatose client receives high priority, and the nurse will utilize the ABCs (airway, breathing, and circulation) of care in this case. Treating the client's pain, taking a history, and triage with other departments are done only after the airway is clear and the client is breathing.