An emergency department triage nurse receives a report that an incoming client has a Glasgow Coma Scale (GCS) score of 8. The nurse alerts the staff that the client's priority intervention is:
1. Assessment of airway, breathing, and circulation.
2. Re-assessment using the FOUR Score Consciousness Scale.
3. Introduction of an intravenous access device.
4. Establishment of orientation to time, place, and person.
Assessment of airway, breathing, and circulation.
Rationale: A GCS (Glascow Coma Scale) score of 8 or less is usually indicative of coma. A comatose client receives high priority, and the nurse will utilize the ABCs of care in this case. None of the remaining options has priority when determining care for the comatose client. Re-assessment using the FOUR Score Consciousness Scale would not be a priority since the client's level of consciousness has already been assessed and established. Assessing the vascular system would be addressed after airway, breathing, and circulation has been deemed stable. Orientation to time, place, and person is not relevant to the care of a comatose client.
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