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    Ngu Hesi Rn Compass Exit Proctored Exam

    The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. Which is the priority nursing intervention based on the client's current GCS?

    Explanation & Rationale

    Rationale: A. Monitor the client every 1 hour for changes in the GCS score: Frequent monitoring is important, but a sudden drop from 13 to 6 indicates significant neurological deterioration that requires immediate reporting rather than just continued observation. B. Prepare the family for the client's imminent death: While family support is important, it is premature to focus on end-of-life discussions before stabilizing the client and notifying the healthcare provider of acute neurological decline. C. Notify the healthcare provider of the GCS score: A GCS of 6 represents severe brain injury and indicates that the client may require urgent interventions, such as airway protection, imaging, or neurosurgical evaluation. Immediate notification of the healthcare provider is the priority action. D. Begin cardiopulmonary resuscitation (CPR): CPR is indicated only if the client is pulseless or apneic. A GCS of 6 reflects decreased consciousness but does not necessarily indicate cardiopulmonary arrest, so CPR is not immediately warranted.

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