The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first?
a. Client with cerebral perfusion pressure of 72 mm Hg
b. Client who has a Glasgow Coma Scale score of 12
c. Client with a PaCO2 of 36 mm Hg who is on a ventilator
d. Client who has a temperature of 102 ° F (38.9 ° C)
ANS: D
A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Coma Scale score of 12, a PaCO2 of 36, and cerebral perfusion pressure of 72 mm Hg are all desired outcomes.
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