A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first?
a. Client with a Glasgow Coma Scale score that was 10 and is now is 8
b. Client with a Glasgow Coma Scale score that was 9 and is now is 12
c. Client with a moderate brain injury who is amnesic for the event
d. Client who is requesting pain medication for a headache
ANS: A
A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.
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