What is the priority intervention on all head injury patients?
Maintenance of patent airway
Maintenance of skin integrity
Prevention of sleep deprivation
Fluid and electrolyte balance
The Correct Answer is A
Choice A: Maintenance of patent airway is correct because it is the most essential and urgent intervention on all head injury patients. A patent airway means that the airway is clear and open for breathing. A head injury can cause obstruction, swelling, bleeding, or paralysis of the airway, leading to hypoxia, brain damage, or death. The nurse should assess and secure the airway as the first step in the primary survey and provide oxygen, suction, or intubation as needed.
Choice B: Maintenance of skin integrity is incorrect because it is not the priority intervention on all head injury patients. Skin integrity means that the skin is intact and free of wounds, infections, or pressure injuries. A head injury can cause skin breakdown, especially in immobilized or unconscious patients. The nurse should prevent and treat skin problems as part of the secondary survey and provide wound care, hygiene, or pressure relief as needed.
Choice C: Prevention of sleep deprivation is incorrect because it is not the priority intervention on all head injury patients. Sleep deprivation means that the patient does not get enough quality or quantity of sleep. A head injury can cause sleep disturbances, such as insomnia, hypersomnia, or altered sleep-wake cycle. The nurse should promote sleep hygiene and rest as part of the ongoing care and provide a quiet, dark, and comfortable environment as needed.
Choice D: Fluid and electrolyte balance is incorrect because it is not the priority intervention on all head injury patients. Fluid and electrolyte balance means that the patient has adequate and stable levels of fluids and minerals in the body. A head injury can cause fluid and electrolyte imbalances, such as dehydration, overhydration, or hyponatremia. The nurse should monitor and regulate fluid and electrolyte status as part of the ongoing care and provide oral or intravenous fluids, medications, or dietary modifications as needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Loss of motor neurons in the brain is not a complete definition of ALS, as it does not include the loss of motor neurons in the spinal cord and brainstem.
Choice B: Loss of sensory neurons in the anterior horn of the spinal cord is not a correct definition of ALS, as it involves sensory neurons, not motor neurons.
Choice C: Loss of motor neurons in the anterior horn of the spinal cord and loss of motor nuclei of the lower brainstem is a correct definition of ALS, as it describes the progressive degeneration and death of both upper and lower motor neurons that control voluntary muscle movements²⁴.
Choice D: All of the above is not correct, as only choice C is a correct definition of ALS.
Correct Answer is A
Explanation
Choice A: Inability to move or respond except for eye movements due to a lesion affecting the pons is a description of locked-in syndrome, as it is a state of complete paralysis and preserved consciousness caused by damage to the brainstem.
Choice B: Unconsciousness, unarousable unresponsiveness is not a description of locked-in syndrome, but rather a description of coma, as it is a state of complete loss of consciousness and reflexes caused by severe brain injury.
Choice C: Unresponsiveness to the environment, makes no movement or sound but sometimes opens eyes is not a description of locked-in syndrome, but rather a description of akinetic mutism, as it is a state of severe apathy and reduced motor activity caused by damage to the frontal lobes or basal ganglia.
Choice D: Devoid of cognitive function but has sleep-wake cycles is not a description of locked-in syndrome, but rather a description of persistent vegetative state, as it is a state of minimal awareness and responsiveness caused by widespread brain damage.
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