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 and mute, which action should the nurse take?
a. Avoid use of the Glasgow Coma Scale.
b. Consider the Babinski response invalid.
c. Utilize a three-point scale to grade muscle strength.
d. Perform the Romberg test with the patient in a seated position.
ANS: A
A limitation of the Glasgow 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. B. The patient's inability to hear or speak will not affect the results of a Babinski reflex assessment. C. The patient's inability to hear or speak will not affect the scale used to grade muscle strength. D. The Romberg test is not completed in the seated position.
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