The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?

Prepare to give phenytoin IV as prescribed.

Perform a substernal rub to evoke a response to pain.

Promptly notify the healthcare provider (HCP) of the GCS score.

Continue monitoring the client's GCS score every 2 hours.

Answer and Explanation

The Correct Answer is D

A. Prepare to give phenytoin IV as prescribed. Phenytoin is used for seizure prophylaxis in clients with moderate to severe head injuries (GCS ≤ 8–10). A GCS score of 14 indicates mild head injury, and prophylactic anticonvulsants may not be necessary unless ordered for specific risk factors.
B. Perform a substernal rub to evoke a response to pain. A substernal rub (painful stimulus) is used to assess response in unconscious or unresponsive clients (GCS ≤ 8). With a GCS of 14, the client is alert or nearly fully conscious, making a painful stimulus unnecessary and inappropriate.
C. Promptly notify the healthcare provider (HCP) of the GCS score. A GCS of 14 is not a critical or emergency finding, as it indicates mild neurological impairment. While the HCP should be updated on significant changes, routine monitoring is sufficient unless deterioration occurs.
D. Continue monitoring the client's GCS score every 2 hours. Frequent neurological assessments are crucial in head injury management to detect worsening conditions like increasing intracranial pressure (ICP) or cerebral edema. Monitoring the GCS every 2 hours ensures timely intervention if the client’s condition changes.

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Correct Answer is A

Explanation

A. Prepare for oral intubation. The client is in severe respiratory distress with oxygen saturation at 88% despite receiving 100% oxygen via a nonrebreather mask. This suggests respiratory failure, likely due to a pulmonary embolism (PE), a known complication following bariatric surgery. Immediate intubation and mechanical ventilation are necessary to prevent further hypoxia and respiratory collapse.
B. Apply leg compression hose. While deep vein thrombosis (DVT) prophylaxis is essential for postoperative bariatric patients, it is not the priority in an acute emergency. Compression devices help prevent clots but do not treat an existing life-threatening pulmonary embolism.
C. Maintain head of bed at 45°. Elevating the head of the bed can help with breathing, but it will not significantly improve oxygenation in a client already failing on 100% oxygen. The priority is to secure the airway with intubation to provide controlled ventilation.
D. Administer an anticoagulant. Anticoagulation is a key treatment for pulmonary embolism, but it does not immediately improve oxygenation or stabilize respiratory function. In a hemodynamically unstable client with severe hypoxia, securing the airway takes priority before initiating anticoagulation therapy.

A. Insert a large bore peripheral IV catheter. B. Raise extremity above the heart. C. Tighten the cloth around the leg. D. Apply ice over the bite mark.

Correct Answer is A

Explanation

A. Insert a large bore peripheral IV catheter. The client is showing signs of shock (tachycardia, hypotension, tachypnea) likely due to envenomation and systemic venom effects. Rapid IV access is essential for fluid resuscitation, administration of antivenom, and management of shock. A large bore (18-gauge or larger) IV catheter allows for aggressive fluid therapy to maintain perfusion and prevent circulatory collapse.
B. Raise extremity above the heart. Elevating the limb can increase venom circulation, worsening systemic effects. Instead, the affected extremity should be kept at heart level to slow venom spread while ensuring adequate perfusion.
C. Tighten the cloth around the leg. Further tightening the makeshift tourniquet can lead to vascular compromise, ischemia, and increased local tissue damage. Modern guidelines discourage tourniquets as they do not prevent venom spread effectively and may worsen outcomes. The best approach is to loosen or remove restrictive bindings and keep the limb immobilized at heart level.
D. Apply ice over the bite mark. Cold therapy is contraindicated as it can worsen tissue damage by causing vasoconstriction, trapping venom, and increasing necrosis. Instead, the priority is IV access, fluid resuscitation, and preparing for possible antivenom administration.

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The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?

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Explanation

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