A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patient's injury is causing increased intracranial pressure (ICP)
The nurse should gauge the patient's LOC on the results of what diagnostic tool?
A) Monro-Kellie hypothesis
B) Glasgow Coma Scale
C) Cranial nerve function
D) Mental status examination
Ans: B
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LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this patient, but would not be the priority in evaluating LOC.
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