The nurse is caring for a patient who was hit on the head with a hammer. The patient was unconscious at the scene briefly but is now conscious upon arrival at the emergency department (ED) with a GCS score of 15
One hour later, the nurse assesses a GCS score of 3 . What is the priority nursing action? a. Stimulate the patient hourly.
b. Continue to monitor the patient.
c. Elevate the head of the bed.
d. Notify the physician immediately.
D
These are classic symptoms of epidural and acute subdural hematomas: injury, lucid period, and progressive deterioration. The physician must be notified of this neurological emergency so appropriate interventions can be implemented. Although elevating the head of the bed, continuously monitoring the patient and applying stimulation as necessary to assess neurological response are appropriate interventions, notification of the physician is a priority given the severity in change of neurological status.
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A) True B) False
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a. Cerebral palsy (CP) b. Multiple sclerosis (MS) c. Myasthenia gravis (MG) d. Parkinson's disease (PD)
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