A client admitted for observation after a head injury has a Glasgow Coma Scale score that fell from 14 to 10 over 30 minutes, and one pupil is now slower to react. Which action should the nurse take first?

• 1 Raise the head of the bed to 30 degrees to aid cerebral venous drainage
• 2 Check a point-of-care glucose to rule out a metabolic cause of the change
• 3 Notify the provider now and prepare the client for urgent brain imaging ✓ Correct answer
• 4 Hold the next prescribed opioid dose and document the neurologic change

For study reference only. Always follow current clinical guidelines and your institution’s protocols.