A nurse is caring for a patient whose blood pressure is 180/…

A nurse is caring for a patient whose blood pressure is 180/100 mmHg. The patient reports a mild headache but no other symptoms.Which of the following activities are considered part of the “Take Action” step in the clinical judgment model? (Select all that apply.)

An adult involved in a motor vehicle accident arrives to the…

An adult involved in a motor vehicle accident arrives to the emergency department. On assessment, the patient’s level of consciousness is reported as opening eyes to pain, responding with inappropriate words, and flexion withdrawal to painful stimuli. Which value will the nurse report for the patient’s Glasgow Coma Scale score?