The nurse is performing a neurologic assessment of a patient whose injuries have rendered her unable to follow verbal commands. How should the nurse proceed with assessing the patient's level of consciousness (LOC)?
A) Assess the patient's vital signs and correlate these with the patient's baselines.
B) Assess the patient's eye opening and response to stimuli.
C) Document that the patient currently lacks a level of consciousness.
D) Facilitate diagnostic testing in an effort to obtain objective data.
Ans: B
Feedback:
If the patient is not alert or able to follow commands, the examiner observes for eye opening; verbal response and motor response to stimuli, if any; and the type of stimuli needed to obtain a response. Vital signs and diagnostic testing are appropriate, but neither will allow the nurse to gauge the patient's LOC. Inability to follow commands does not necessarily denote an absolute lack of consciousness.
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