A client with a neurologic deficit has been admitted to your unit. The nurse caring for the client is assessing the client and observes significant changes in the client's status. Which of the following action should the nurse perform immediately?
A) Use the Glasgow Coma Scale.
B) Use the Mini-Mental Status Examination.
C) Report the change to the physician.
D) Monitor the blood pressure.
C
Feedback:
When significant changes occur, the nurse should immediately report them to the physician. The nurse uses the Glasgow Coma Scale or other neurologic assessment tools, such as the Mini-Mental Status Examination, to perform the neurologic assessments to evaluate the client's status. The nurse maintains the blood pressure to ensure adequate cerebral oxygenation.
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