18. A nurse notes that a client, who experienced a head injury 24 hours ago has returned to the emergency department with slurred speech and is disoriented to time and place. The first nursing action should be to:
18. A nurse notes that a client, who experienced a head injury 24 hours ago has returned to the emergency department with slurred speech and is disoriented to time and place. The first nursing action should be to:
. Continue to assess hourly as ordered.
. Report the change to the physician.
. Repeat a neurologic assessment in 15 minutes.
. Notify the operating room of the need for surgery.
Test-Taking Tip
A change in level of consciousness requires immediate notification of the physician.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because a delay in treatment could result in irreversible damage. Answer 2 is correct because a medical or surgical intervention is needed for an apparent increase in intracranial pressure. Answer 3 is incorrect because a change in level of consciousness is an early sign of increased intracranial pressure that requires an intervention. Answer 4 is incorrect because this is not the RN's role.