Difficulty: Medium
Average Score: 72%
Simulated
A nurse in an emergency department is caring for a client who has a closed head injury. Which of the following actions should the nurse take first?
Correct answer
C
Rationale
The correct answer is C: Determine the client's Glasgow Coma Scale score. This is the first action the nurse should take because it provides crucial information about the client's level of consciousness, helps in monitoring neurological status, and guides further interventions. It is important to assess the client's neurological status promptly in a closed head injury to identify any deterioration or changes in condition.
Preparing the client for an MRI (A) is important but not the first priority. Inserting an indwelling urinary catheter (B) may be necessary but does not address the immediate need for neurological assessment. Administering mannitol IV bolus (D) may be indicated to reduce intracranial pressure, but assessing the client's Glasgow Coma Scale score should come first to guide this intervention.
Preparing the client for an MRI (A) is important but not the first priority. Inserting an indwelling urinary catheter (B) may be necessary but does not address the immediate need for neurological assessment. Administering mannitol IV bolus (D) may be indicated to reduce intracranial pressure, but assessing the client's Glasgow Coma Scale score should come first to guide this intervention.