The Nurse Is Caring for a Patient with a Head

Multiple Choice

The nurse is caring for a patient with a head injury.Over a time span of 30 minutes,the nurse observes the following vital signs changes: temperature from 97° to 98° F; pulse from 86 to 78 beats/min; respirations from 18 to 14 breaths/min; and blood pressure from 140/86 to 150/82.Which action is most important for the nurse to take?

A) Notify the physician immediately.
B) Document the findings.
C) Determine the patient's Glasgow Coma Scale (GCS) score.
D) Observe pupils for size, equality, and reactivity.