hard · NCLEX-RN management
A mechanically ventilated client has a severe traumatic brain injury. The hospital's jointly approved OPO referral policy requires prompt notification for absent brainstem reflexes, planned discussion of withdrawal of life-sustaining treatment, or a GCS score of 5 or less. Which situations require the RN to notify the OPO? Select all that apply.
- The client has a documented loss of corneal and pupillary reflexes.
- The primary healthcare provider and family are planning to discuss withdrawal of life-sustaining treatment.
- The nurse plans to perform a clinical assessment for neurologic determination of death while the client's core temperature is 34.5°C (94.1°F).
- The client's Glasgow Coma Scale (GCS) score decreases to 4.
- The family asks about the client's prognosis, prompting the nurse to initiate a discussion about organ donation options.
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