The nurse is caring for a 22-year-old female patient who is 2 days post craniotomy for a brain tumor. She was doing well until 2 a.m., when she begins crying and asks for her mother
She has a Glasgow Coma Scale (GCS) of 15, and pupils are equal and reactive. Her mother is sleeping in the visitors' lounge. What nursing action would be most appropriate at this time?
a. Administer an as-needed sedative to calm the patient.
b. Notify the neurosurgeon that the patient is upset and crying.
c. Ask the mother to come and stay with the patient.
d. Reassure the patient, and sit with her until she falls back asleep.
ANS: C
A GCS of 15 and other assessment findings show the patient is stable. She has been through tremendous stress and wants her mother. There is no reason not to ask the mother to come and stay with her. A sedative is not indicated and may mask assessment findings. There is no reason to contact the surgeon.
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