# 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?

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=522678&lang=en  
> language: en  
> subject: Alterations in Body Systems  
> category: PA

## Question

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?

## Option

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

**Correct answer: 3**

## Explanation

A falling score with a new unequal pupil response suggests an expanding intracranial lesion. Imaging and provider evaluation determine whether surgical decompression is needed, so escalation comes first.

## In-depth explanation

Quick answer
Notify the provider and prepare for urgent imaging of the head.

Why this is correct
A sharp drop paired with a new pupil finding is a focal sign, not a general decline. Only imaging distinguishes a lesion that needs decompression from one that can be observed, and that decision belongs to the provider.

Easy analogy or mental picture
The pupil change is a warning light that calls for a diagnostic scan, not a dashboard reset. The comparison stresses urgency and does not imply that positioning is abandoned.

Memory hook
A falling score with a lagging pupil is imaged, not observed.

NCLEX decision rule
When consciousness falls together with a new focal neurologic sign, escalate for imaging first. Supportive nursing measures continue but do not substitute for the diagnostic decision.

Why the other choices are wrong
Head elevation, glucose testing, and reviewing sedating drugs each belong in the care of altered consciousness, yet each one delays the imaging that changes management.References

- [1]NCSBN: 2026 NCLEX-RN Test PlanNational Council of State Boards of Nursing

- [2]MedlinePlus: Head Injury First AidU.S. National Library of Medicine

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