A client is being evaluated every 8 hours using the Glasgow Coma Scale. At 0800 the client's score is 13, and at 1600 the client's score is 10 . Which action should the nurse take NEXT?
a. Bring the score to the health care provider's attention during rounds.
b. Call the health care provider now.
c. Chart the score and repeat the evaluation as ordered.
d. Chart the score and repeat the evaluation in 4 hours.
B
A score of 15 indicates a fully oriented person. A score of 3 is the lowest possible score, indicating deep coma. A score of 7 or less is considered a state of coma. Changes in the Glasgow Coma Scale indicate changes in the client's condition warranting a call to the healthcare provider.
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