Question

The nurse cares for a client following traumatic brain injury. The client's Glasgow Coma Scale score is 11. Which signs and symptoms does the nurse report immediately to the HCP?

1) The client reponds to pain only, has incomprehensible speech, and withdraws only to pain.
2) The client responds to verbal command, is confused, and obeys command for movement.
3) The client opens eyes spontaneously, is oriented, and obeys commands for movement.
4) The client reponds to verbal command, answers questions appropriately, and withdraws to touch.

Answer 1

The nurse should immediately report scenario 1 where the client shows signs of significant impairment such as responding to pain only and having incomprehensible speech, as these may indicate a more severe change in condition.

Step-by-step explanation:

If a client who sustained a traumatic brain injury has a Glasgow Coma Scale score of 11, the nurse should be vigilant for any signs and symptoms that indicate a worsening condition. Out of the options provided, the first scenario (1) where the client responds to pain only, has incomprehensible speech, and withdraws only to pain, may represent a more acute or severe change in neurological status and should be reported immediately to the Healthcare Provider (HCP). These symptoms suggest significant impairment in both consciousness and motor response, as well as no meaningful verbal communication. The other options represent less severe symptoms that, while may require monitoring, do not indicate an immediate acute concern based on the Glasgow Coma Scale assessment.

Serious brain injuries can cause various symptoms that range from the loss of consciousness to confusion and motor deficits. The underlying causes could range from trauma to strokes, and each symptom helps narrow down the affected area in the brain. It is crucial for healthcare providers to rapidly assess and respond to changes in a patient's neurological status to prevent further complications and to improve the prognosis.