Location: Preoperative surgical unit
Time: 0730
Report from the night shift nurse:
Situation: Edith Jacobson is an 85-year-old female who was admitted last evening after a fall at home where she fractured her left hip and hit her head. An x-ray has been taken and shows a left intertrochanteric hip fracture. ECG showed normal sinus rhythm, no ectopic beats. She also had a CT of her head, and results were negative for intracranial bleeding. Her relative was visiting her when the patient tripped on the edge of a rug and is currently at Edith's bedside.
Background: Edith Jacobson has a 10-year history of osteoporosis and no known allergies.
Assessment: Edith Jacobson's vital signs are stable. Her pain is under control with morphine every 4 hours. I medicated her at 0600 for a pain level of 8. Her pain level is a 2 after the morphine. I just turned her and assessed the fractured hip. The skin is intact, and the color, motion, and sensation around the hip area are within normal limits. She has no visible wounds to her head. A fall risk assessment was completed on admission, and her Morse Fall Scale score was 45. Fall precautions were implemented. Her Glasgow Coma Scale score was 15. The patient has been oriented to person, place, time, and situation this morning.
Recommendation: Edith Jacobson's provider has ordered a neuro check. I would like you to perform another Glasgow Coma Scale. You should also reinforce safety and provide fall risk education. The nurse's initial assessment of Edith Jacobson will include documenting neurologic status using the Glasgow Coma Scale (GCS).
Which of the following finding(s) would be consistent with a GCS score of 15? (Select all that apply.)
A. Obeying two-part request to open mouth and stick out tongue
B. No movement in arms or legs without interfering factor
C. Spontaneously opening the eyes
D. Opening eyes after fingertip stimulus
E. Correctly giving name, place, and date
F. Using intelligible single words