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The Nurse Is Completing a Glasgow Coma Scale Reassessment of a Client

Question 5

Multiple Choice

The nurse is completing a Glasgow Coma Scale reassessment of a client who fell down a flight of stairs 8 hours ago.On admission,the client displayed spontaneous eye opening.The nurse does not see this response at this time and knows to do which to know if the client responds at the next level of eye opening?


A) Provide painful stimuli to evoke eye opening.
B) Request the client speak his own name.
C) Tell the client to "open his eyes" or to look at the nurse.
D) Ask the client to squeeze the nurse's hand.

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