A client sustained a head injury from a lead pipe two hours ago and is admitted for observation. A CT scan indicates no spinal cord injury or skull fractures. The client begins projectile vomiting, prompting the nurse to turn the client's head to the side and administer ondansetron 4 mg IV as prescribed. Reassessment shows a Glasgow Coma Score of 13, and the left pupil is dilated and unresponsive to light.

Which intervention(s) should the nurse implement? Select all that apply.

A. Insert a second large-bore IV catheter.
B. Repeat the Glasgow Coma Scale assessment.
C. Apply artificial tear drops to the left eye.
D. Schedule a repeat CT scan.
E. Place the client in the lateral Trendelenburg position.

The nurse should repeat the Glasgow coma assessment, schedule a repeat CT scan, and consider inserting a second large bore IV catheter due to the patient's neurological symptoms. These interventions are crucial for monitoring and managing potential increased intracranial pressure. Options for eye care and patient positioning are less critical in this acute context.

Explanation:

Patient Assessment and Interventions Following Head Injury

The scenario describes a patient who has sustained a head injury with subsequent symptoms that need careful monitoring and intervention. Given the patient's Glasgow Coma Score (GCS) of 13, alongside a dilated left pupil that does not react to light, these signs may indicate increased intracranial pressure (ICP) or potential brain injury.

Recommended Nursing Interventions

Considering the patient’s situation, the following interventions are warranted:

B - Repeat Glasgow coma assessment. This is critical to monitor any changes in the patient's neurological status.
D - Schedule a repeat CT scan. This is essential to rule out any evolving intracranial pathology, especially due to the unilateral pupil dilation.
A - Insert a second large bore IV catheter. This is important for possible emergency interventions or medication administration, especially if the patient's condition deteriorates.

While options C (applying artificial tear drops) and E (placing in lateral Trendelenburg position) might seem relevant, they are not appropriately indicated in this scenario. Artificial tears may be necessary for eye protection, but they are less urgent compared to the need for further assessments and imaging.

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