An emergency department (ED) nurse receives a report that an incoming patient has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse?
1. Treat the patient's pain.
2. Assess the patient's airway, breathing, and circulation.
3. Obtain a complete history from the patient.
4. Triage the patient with the other ED patients.
2
Rationale 1: Another action is the nurse's priority.
Rationale 2: The GCS (Glasgow Coma Scale) is a standardized system for assessing consciousness. A score of 15 indicates full alertness, and a score of 8 or less is usually indicative of coma. A comatose patient receives high priority, and the nurse will utilize the ABCs of care in this case. Additionally, assessment is the first step of the nursing process.
Rationale 3: This patient will not be able to respond to questions.
Rationale 4: The patient should receive priority care in the ED.
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