A patient with a head injury has a Glasgow Coma Scale score that falls from 14 to 10 over one hour. What is the nurse's priority action?
Correct answer: C. Report the deterioration immediately and reassess airway
- A. Allow the patient to sleep without interruption
- B. Offer oral fluids to prevent dehydration
- C. Report the deterioration immediately and reassess airway
- D. Administer a sedative before repeating the assessment
Explanation
A falling Glasgow Coma Scale score suggests worsening neurological function and may threaten airway protection. The nurse should reassess airway and breathing and report the change urgently; sedation can further obscure neurological assessment.
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About Burns and Trauma Nursing
Covers the initial and continuing care of patients with burns, haemorrhage, fractures, head injury, chest trauma and shock. It includes burn depth and surface-area estimation, airway protection, fluid resuscitation, wound care, infection prevention, pain management and the distinction between hypovolaemic, septic and neurogenic shock.
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50 free Burns and Trauma Nursing MCQs from Medical Surgical Nursing, each with the correct answer and an explanation. Unlimited attempts, no account needed.
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