# A client with a head injury has a Glasgow Coma Scale score that decreased from 14 to 10. Which action should the nurse take first?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=397148&lang=en  
> language: en  
> subject: Hemodynamics  
> category: PA

## Question

A client with a head injury has a Glasgow Coma Scale score that decreased from 14 to 10. Which action should the nurse take first?

## Option

1. Document the finding and recheck in 4 hours.
2. Offer a quiet environment to promote sleep.
3. Notify the provider and prepare for urgent evaluation. **✔ Correct answer**
4. Give oral fluids to improve cerebral perfusion.

**Correct answer: 3**

## Explanation

A decreasing level of consciousness after head injury is a serious neurologic change and may indicate worsening intracranial pressure or bleeding. The provider should be notified promptly for urgent evaluation. Waiting, promoting sleep, or giving oral fluids does not address the acute neurologic deterioration.

## In-depth explanation

Clinical Judgment
Use the client cues, timing, labs, and safety risks to select the response that best fits Head injury neurologic decline.

Memory Tip
Match the strongest cue cluster to the safest nursing judgment.

KR vs US
NCLEX items reward cue-based priority thinking rather than isolated recall.

## Clinical scenario

Clinical Practice Guide
For Head injury neurologic decline, compare the complete cue pattern with the client's current stability, ordered data, and expected nursing scope.

Caution
Do not choose an action from one isolated cue when the full scenario changes priority or safety.

## Key concepts

- **Glasgow Coma Scale** — A tool used to assess eye opening, verbal response, and motor response.
- **Intracranial Pressure** — Pressure inside the skull that can compromise cerebral perfusion.
- **Neurologic Deterioration** — A worsening in level of consciousness, movement, pupils, or other neurologic signs.

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