The nurse is providing care for a client admitted to the hospital after a motor vehicle accident. After being informed by family members that the patient is deaf-mute, which of the following actions should the nurse take?
a. Utilize a three-point scale to grade muscle strength.
b. Consider the Babinski response invalid.
c. Avoid use of the Glascow Coma Scale.
d. Perform the Romberg test with the patient in a seated position.
ANS: C
A limitation of the Glascow Coma scale is that if one of the three components cannot be measured, the resulting score is of no use. Because it is not possible to fully evaluate verbal responses for this patient, the scale should not be used.
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