Following a traumatic brain injury sustained in an automobile accident, a client is closely monitored in the intensive care unit . When planning the client's care, which action should the nurse identify as most critical for this client?
A. Assess pupil size and accommodation every six hours
B. Administer acetaminophen 325 mg orally for headache
C. Accurately document Glasgow Coma Scale every hour
D. Administer ondansetron 4 mg IV push after client vomits