QuestionAugust 15, 2025

A client who has experienced trauma is admitted to the intensive care unit.The nurse's initial assessment includes a Glasgow Coma Scale (GCS) score of 3, pupils fixed and dilated with an absence of corneal reflex , blood pressure of 80/30 mmHg, and core temperature of 95.7^circ F(35.4^circ C) . The client's spouse asks the nurse when the client will wake up . How should the nurse respond? "Your spouse's condition indicates irreversible damage." "Let me contact the healthcare provider to answer your questions." "Each person is different and we need to wait and see what happens." "I need to initiate the volume expanders and warming blanket to stimulate a response."

A client who has experienced trauma is admitted to the intensive care unit.The nurse's initial assessment includes a Glasgow Coma Scale (GCS) score of 3, pupils fixed and dilated with an absence of corneal reflex , blood pressure of 80/30 mmHg, and core temperature of 95.7^circ F(35.4^circ C) . The client's spouse asks the nurse when the client will wake up . How should the nurse respond? "Your spouse's condition indicates irreversible damage." "Let me contact the healthcare provider to answer your questions." "Each person is different and we need to wait and see what happens." "I need to initiate the volume expanders and warming blanket to stimulate a response."
A client who has experienced trauma is admitted to the
intensive care unit.The nurse's initial assessment includes a
Glasgow Coma Scale (GCS) score of 3, pupils fixed and dilated
with an absence of corneal reflex , blood pressure of
80/30
mmHg, and core temperature of 95.7^circ F(35.4^circ C) . The client's
spouse asks the nurse when the client will wake up . How
should the nurse respond?
"Your spouse's condition indicates irreversible damage."
"Let me contact the healthcare provider to answer your questions."
"Each person is different and we need to wait and see what
happens."
"I need to initiate the volume expanders and warming blanket to
stimulate a response."

Solution
4.1(311 votes)

Answer

"Let me contact the healthcare provider to answer your questions." Explanation 1. Assess the Clinical Indicators The GCS score of 3, fixed and dilated pupils, absence of corneal reflex, low blood pressure, and hypothermia indicate severe neurological impairment and critical condition. 2. Determine Appropriate Response Given the severity of the clinical indicators, the nurse should avoid giving false hope or making medical predictions. Contacting the healthcare provider is appropriate for addressing complex questions.

Explanation

1. Assess the Clinical Indicators<br /> The GCS score of 3, fixed and dilated pupils, absence of corneal reflex, low blood pressure, and hypothermia indicate severe neurological impairment and critical condition.<br /><br />2. Determine Appropriate Response<br /> Given the severity of the clinical indicators, the nurse should avoid giving false hope or making medical predictions. Contacting the healthcare provider is appropriate for addressing complex questions.
Click to rate:

Similar Questions