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A Client Was Struck on the Head by a Baseball

Question 176

Multiple Choice

A client was struck on the head by a baseball bat during a robbery attempt.  The nurse gives this report to the oncoming nurse at shift change and conveys that the client's current Glasgow Coma Scale (GCS) score is a "10."  Which client assessment is most important for the reporting nurse to include?


A) Belief that the current surroundings are a racetrack
B) GCS score was "11" one hour ago
C) Recent vital signs show blood pressure of 120/80 mm Hg and pulse of  82/min
D) Reported allergy to penicillin and vancomycin

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