Nursing Prioritization Delegation Assignment Q 40

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Nurse Janus enters a room and finds a client lying on the floor. Which of the following actions should the nurse perform first?

  

     A. Call for help to get the client back in bed

     B. Establish whether the client is responsive

     C. Assist the client back to bed

     D. Ask the client what happened

    

    

Correct Answer: B. Establish whether the client is responsive

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Assess the client’s current level of consciousness first to determine whether the patient has had a loss of consciousness then do the remaining choices if possible. The initial step is to evaluate for reactivity using objective measures. Address the patient verbally, progress to light shaking, then progress to more intense mechanical stimulation.

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Option A: After establishing the client’s ABCs, the nurse may call for help. The initial step in the evaluation of an unconscious patient is to evaluate for the basic signs of life. The American Heart Association recommends examining for a pulse, followed by assessing airway patency and breathing pattern.

Option C: If the client is stable and has been seen by a physician, the nurse may assist him back to his bed. The best practice for reporting level of responsiveness is to document specifically how the patient reacted to the external stimulus provided for testing.

Option D: History regarding an unconscious patient is based on supplementary data. Questioning a person who has good knowledge of the recent history of the patient is preferable. The physical exam should be repeated at least daily, in a sequential fashion, and documented systematically.

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