Answer :
Final answer:
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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