Question

The nurse has just received report on a group of clients on the neurosurgical unit. Which client will be the nurse's first priority?

A) Young adult client whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10
B) Adult client whose deep tendon reflexes have become hyperactive
C) Middle-aged client who displays plantar flexion when the bottom of the foot is stroked
D) Older adult client who consistently demonstrates decortication when stimulated

Answer 1

The nurse should prioritize the young adult client with a dramatic decrease in Glasgow Coma Scale rating due to the urgent need to address potential rapid neurological deterioration. Rapid neurological assessment is critical in emergencies to identify injury severity and location for prompt treatment.

Step-by-step explanation:

The nurse's first priority in the neurosurgical unit should be the young adult client whose Glasgow Coma Scale (GCS) rating has changed from 15 to 10. A change in the GCS indicates a potential for rapid deterioration of neurological status and requires immediate attention. This takes precedence over hyperactive deep tendon reflexes, normal plantar flexion in response to stroking the bottom of the foot, or consistent decortication, which, while serious, do not indicate a change in status as acute or potentially life-threatening as a deterioration in consciousness.

Rapid assessment of neurological function is crucial in emergency situations because it provides quick and essential information about the location and severity of a neurological injury. This information is vital for timely and appropriate treatment, such as the initiation of stroke protocols like CT scans and treatment with aspirin therapy to limit blood clot formation. A comprehensive neurological assessment includes the evaluation of reflexes, sensorimotor function, language comprehension, and the ability to follow instructions, all of which contribute to developing a treatment plan.