It is 40 minutes after the nurse has completed her beginning…
It is 40 minutes after the nurse has completed her beginning of shift assesment on a client who fell 30 feet on a construction site 3 hours ago. The client had a Glasgow Coma Scale (GCS) score of 15 at initial assessment. The nurse noticed the client’s eyes were closed. A loud noise occurred in the ICU and the client’s arms and legs jerked under the covers then slowly relaxed while his eyes remained closed. Which thought process is most appropriate in this situation?