Components of the Glasgow Coma Scale (GCS) the nurse would use to assess a patient after a head injury include which assessment?
a. Blood pressure
b. Cranial nerve function
c. Head circumference
d. Verbal responsiveness
ANS: D
Components of the GCS include eye opening, motor responsiveness, and verbal responsiveness. The nurse would want to assess the blood pressure, but this is not a component of the coma scale. Assessment of cranial nerve function is appropriate as alterations such as cranial nerve VI palsies may occur, but this is not part of the coma scale. Increases in head circumference are associated with alterations in intracranial pressure in infants, but this is not part of the coma scale.
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