1330: A 15-year-old female was participating in cheerleading practice and fell to the ground while in the air. Witnesses said that she hit her head and 'blacked out,' and the client reports no recall of the event. The client endorses left occipital head pain with tenderness to the affected area. Slight swelling noted. The client reports headache as a '7' (0 = no pain, 10 = worst pain). She is lethargic and oriented.
Oral temperature 97° F (36° C)
Pulse 78 bpm
Respirations 17/minute
BP 117/70 mm Hg
Oxygen saturation 95% on room air.
The nurse assigned to the client reviews the triage note and plans care
➢ The nurse anticipates taking which action? Select if the potential nursing action is indicated or inappropriate
- A. Prepare the client for a computed tomography (CT) scan of the head
- B. Perform a Glasgow Coma Scale (GCS)
- C. Encourage by mouth (PO) fluids
- D. Assess the client's pupils
- E. Prepare the client for a lumbar puncture (LP)
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