A nurse is caring for a 10-year-old child with a brain injury. On assessing the child, the nurse finds the following data: opens eyes only to pain, mutters inappropriate words, has abnormal extension to stimulation. Which action by the nurse takes priorit
A.
Alert the operating room for emergent surgery.
B.
Document the findings; reassess in 15 minutes.
C.
Notify the provider; prepare for intubation.
D.
Raise the head of the child's bed to 45 °.
ANS: C
A child with a Glasgow Coma Score of less than 8 needs to be intubated and mechanically ventilated. This child's score is 7 (eye opening = 2, verbal response = 3, motor response = 2). The child may need an invasive procedure due to the increased intracranial pressure, but this would not take priority over managing the airway and providing adequate oxygenation. The findings need to be documented, but further action is needed. Raising the head of the bed may or may not be beneficial, but does not take priority over intubation.
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