The nurse decides to use the Un-Responsiveness (FOUR) Score Coma Scale to determine a client's level of consciousness. What client finding caused the nurse to make this decision?
1. Deafness
2. Fractured left leg
3. Prescribed opioid analgesics
4. Wears prescription eyeglasses
1
Rationale 1: Un-Responsiveness (FOUR) Score Coma Scale is used to assess coma in the neurologic client. It differs from the Glasgow Coma Scale by not requiring a verbal response.
Rationale 2: The Un-Responsiveness (FOUR) Score Coma Scale is not indicated in a client with a fracture.
Rationale 3: The Un-Responsiveness (FOUR) Score Coma Scale is not indicated in a client taking opioid analgesics.
Rationale 4: The Un-Responsiveness (FOUR) Score Coma Scale is not indicated in a client wearing prescription eyeglasses.
Global Rationale: Un-Responsiveness (FOUR) Score Coma Scale is used to assess coma in the neurologic client. It differs from the Glasgow Coma Scale by not requiring a verbal response. The Un-Responsiveness (FOUR) Score Coma Scale is not indicated in a client with a fracture, use of opioid analgesics or wearing prescription eyeglasses.
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