The Nurse Enters a Client's Room with a Suspected Head

Multiple Choice

The nurse enters a client's room with a suspected head injury in preparation for completing a neurological assessment that includes a Glasgow Coma Score (GCS) .Upon entering the room and turning on a light,the nurse notes that the client doesn't open his eyes immediately.Which is the nurse's next action?

A) Complete the client's vital signs and recheck the client in 30 minutes.
B) Gently touch the client's arm to see if the client spontaneously awakens.
C) Turn the light off,leave the room,and document that the client is sleeping.
D) Vigorously rub the client's sternum to determine if the client responds to painful stimuli.