A nurse is caring for a client who has a traumatic brain injury. The client, who...

A nurse is caring for a client who has a traumatic brain injury. The client, who has been quiet and cooperative, becomes agitated and restless. Which of the following assessments should the nurse perform first?

a. Blood glucose
b. Urinary output
c. Motor responses
d. Blood pressure

Solutions

Expert Solution

Option C Motor Responses

Assessment of motor response is designed to determine the patient's ability to obey a command and to localise, and to withdraw or assume abnormal body positions, in responseto a painful stimulus .

Therefore a nurse should perform motor response first so that patient can be easily cured

Procedure for motor response

Ascertain the patient’s acuity of hearing.
Ideally, use an interpreter if the patient does not speak English.
Check the patient’s notes for any medical condition that may affect the accuracy of the GCS, for example previous stroke, affecting the movement of the patient’s arms
Check the neurological observation chart for the GCS scale
Check if the patient opens their eyes without the need to speak or to touch them; if the patient does, then the score is 4E.
If the patient does not open their eyes, talk to them . Start off with a normal volume and speak louder if necessary. If they now open their eyes, the score is 3E.
If the patient does not open their eyes to speech, administer a painful stimuli, for example trapezium squeeze (using the thumb and two fingers grasp the trapezius muscle where the neck meets the shoulder and twist ) Or apply suborbital pressure (locate the notch on the suborbital margin and apply pressure to it) . An alternative is the sternal Rub
If the patient opens their eyes to a painful stimulus record the score as 2E If the patient does not respond, then the score is 1E.

Nightingale answered 1 year ago

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