A patient with a head injury is being monitored in the emergency unit. Which change should the nurse document as a possible early neurological deterioration?
Correct answer: B. New inability to obey a simple command
- A. Increasing alertness after rest
- B. New inability to obey a simple command
- C. Pulse of 76 beats per minute
- D. Equal hand grips bilaterally
Explanation
A new inability to follow commands suggests worsening level of consciousness or neurological function and requires prompt reporting. Normal pulse and equal hand grips do not indicate deterioration in this situation.
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About Neurological Nursing
Covers nursing assessment and management of stroke, epilepsy, meningitis, raised intracranial pressure, head injury, spinal cord disorders, Parkinson disease and multiple sclerosis. Key areas include level of consciousness, pupil responses, motor and sensory findings, seizure precautions and distinguishing upper motor neuron from lower motor neuron signs.
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