A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next?

Check the client's pupils for equality and reaction to light

Measure the client's alertness using the Glasgow Coma Scale

Immobilize the client's cervical spine

Question the client's coworkers about the mechanism of injury

Answer and Explanation

The Correct Answer is C

A. Assessing pupils is important but should follow spinal precautions to prevent further injury.
B. Glasgow Coma Scale assessment is vital but should not delay spinal immobilization.
C. Immobilizing the cervical spine is a priority to prevent potential spinal cord injury after trauma, especially with head injury and falls. It must be done before moving or further assessment.
D. Gathering history is helpful but is secondary to ensuring patient safety through stabilization.

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Correct Answer is C

Explanation

A. Cervical traction is a method used to help achieve spinal stabilization, but it is a technique rather than the overarching priority.
B. Spinal fusion is a surgical (operative) treatment and therefore not considered a nonoperative approach.
C. Stabilization is the priority nonoperative treatment to prevent further injury to the spinal cord and surrounding structures. It may involve immobilization with collars, braces, or traction.
D. Pain management is important for comfort but is not the immediate priority when spinal cord stability and neurologic function are at risk.

A. Assess the client for bladder distention. B. Administer a nitrate antihypertensive. C. Place the client in a high-Fowler's position. D. Obtain the client's heart rate.

Correct Answer is C

Explanation

A. Bladder distention is a common trigger of autonomic dysreflexia, but the immediate priority is to reduce blood pressure by positioning the patient.
B. Antihypertensive medication may be necessary, but nonpharmacologic interventions such as positioning and removing the triggering stimulus should be done first.
C. Placing the client in a high-Fowler’s position is the first action to lower blood pressure by promoting venous pooling in the lower extremities, thereby reducing cerebral blood pressure and minimizing the risk of stroke.
D. Heart rate monitoring is part of the assessment but does not take priority over immediately addressing the dangerously high blood pressure.

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A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next?

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Which is a priority nonoperative treatment following a spinal cord injury?

Correct Answer is C

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)?

nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?

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For the patient with a closed head injury from a blunt object, which assessment would the nurse perform as the most reliable clinical indication of a patient's development of an increased intracranial pressure (ICP)?

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To prevent the leading cause of death for clients with spinal cord injury, collaboration with which member of the interprofessional health care team is a nursing priority?

The nurse is caring for a client with a traumatic brain injury following a motor vehicle collision. The client is completely unresponsive to verbal or physical stimuli and does not open the eyes. Which prescription should the nurse clarify with the health care provider?

A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next?