The intensive care unit nurse is preparing to assess the level of consciousness of a client who is intubated and has both hands restrained to prevent the client from pulling out the endotracheal tube. The client's injury occurred due to a stabbing incident that ultimately caused the client to fall and hit his head. Which item related to the client will cause the nurse to report an incomplete Glasgow Coma Score (GCS)?
A. The client is intubated.
B. The client's hands are restrained.
C. The client was stabbed.
D. The client fell and hit his head.
Answer: A
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