SDL 4 Head and leg trauma and shock

Ms. A, a 20-year-old college student who had been drinking at a

fraternity party before she fell from a second-floor balcony, has
just arrived in the emergency department (ED). A fellow college
student who accompanies Ms. A tells you, “She was completely
knocked out right after the fall. But then she woke up a little, so
we thought she was okay—until she stopped moving again.”
You are assigned as the ED triage nurse. When you assess Ms.
A, there is no response to commands or to having her name
called. She extends her arms and legs stiffly when nail bed
pressure is applied, but there is no verbal response. Her eyes
are shut, and she does not open them even with the nail bed
pressure. When you open her eyelids, you see that her pupils
are unequal, with the right pupil larger than the left. The pupil
response when you shine a flashlight into her eyes is sluggish.
Ms. A’s blood pressure is 70/30 mm Hg, she is in a sinus
bradycardia with a rate of 40 beats/min, and her respiratory rate
is 6 breaths/min. Her respirations are irregular, and she has 20-
second periods of apnea. You note that she has a large occipital
laceration and that her left leg is misaligned. The paramedics
have a cervical collar and backboard in place. A 16-gauge
catheter has been inserted at the left antecubital area and
lactated Ringer’s solution is infusing at 150 mL/hr
Questions:
1. What are the possible additional assessment you can
obtain to the patient at this time(give 5)
2. Write down the Glasgow Coma Scale. And what do you
think is the GCS of your patient?
3. Base on the case , what are your possible nursing
diagnosis(give 3 and there intervention)
4. Give me short explanation of shock

Note: Same instruction