A client with increased intracranial pressure caused by a traumatic brain injury is in a coma. What approach should the nurse use to assess this client's impaired consciousness?
1. Glasgow Coma Scale
2. Determine degree of brainstem reflexes
3. Assess pupillary response to light and accommodation
4. Use the Un-Responsiveness (FOUR) Score Coma Scale
4
Rationale 1: A nonverbal client cannot respond to parameters assessed using the Glasgow Coma Scale.
Rationale 2: Brainstem reflex assessment would help determine if the client is brain dead.
Rationale 3: Pupillary response to light and accommodation determines the functioning of cranial nerves II and III.
Rationale 4: Un-Responsiveness (FOUR) Score Coma Scale is used to assess coma in the neurologic client. This tool scores four components of impaired consciousness: eye response, motor response, brainstem reflexes, and respiration. It differs from the Glasgow Coma Scale by not requiring a verbal response.
Global Rationale: Un-Responsiveness (FOUR) Score Coma Scale is used to assess coma in the neurologic client. This tool scores four components of impaired consciousness: eye response, motor response, brainstem reflexes, and respiration. It differs from the Glasgow Coma Scale by not requiring a verbal response. A nonverbal client cannot respond to parameters assessed using the Glasgow Coma Scale. Brainstem reflex assessment would help determine if the client is brain dead. Pupillary response to light and accommodation determines the functioning of cranial nerves II and III.
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