A client is seen in the emergency department with severe pain related to a sickle cell crisis. What does the nurse understand is occurring with this client?

Reasoning:

Choice A reason: The Glasgow Coma Scale (GCS) provides a standardized score for consciousness, not an in-depth neurological assessment. It evaluates eye, verbal, and motor responses but does not detail specific neurological deficits like cranial nerve function, requiring additional tests for a comprehensive neurological evaluation.

Choice B reason: The GCS does not assess knowledge of preceding events, which relates to memory or orientation, not consciousness. Amnesia or cognitive deficits are evaluated separately. The GCS focuses on immediate responses to stimuli, providing a snapshot of consciousness, not historical knowledge.

Choice C reason: The GCS assesses the client’s current level of consciousness by scoring eye opening, verbal response, and motor response. Trending scores over time indicates changes in consciousness, reflecting neurological status in conditions like head injury, guiding interventions and prognosis in critical care settings.

Choice D reason: The GCS does not measure the “lowest” verbal and physical response but the best response to stimuli at the time of assessment. It quantifies consciousness, not minimal function. Scores reflect current neurological status, not the worst possible responses, making this inaccurate.

Reasoning:

Choice A reason: A chest x-ray evaluates cardiopulmonary conditions but is not the initial test for CVA. It may be used to rule out secondary issues, but brain imaging is critical to differentiate ischemic from hemorrhagic stroke, guiding treatment like thrombolytics, making chest x-ray less urgent.

Choice B reason: A brain CT scan or MRI is the initial diagnostic evaluation for CVA to distinguish ischemic from hemorrhagic stroke. CT is faster and widely used to rule out hemorrhage before thrombolytic therapy, ensuring safe treatment. MRI provides detailed imaging but is less common in emergencies due to time constraints.

Choice C reason: Prothrombin level assesses coagulation but is not the initial test for CVA. It is relevant for patients on anticoagulants or before thrombolytics, but brain imaging takes precedence to confirm stroke type and guide urgent treatment, making coagulation tests secondary.

Choice D reason: Lumbar puncture is not routine for CVA diagnosis, as it risks brain herniation in cases of increased intracranial pressure. It may be used for subarachnoid hemorrhage if imaging is inconclusive, but brain CT or MRI is the primary and safer initial evaluation.