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 D
Explanation
Choice A: Return to hospital immediately if patient is having severe headache or vomiting is correct because it can indicate increased intracranial pressure, bleeding, swelling, or infection in the brain. These are serious complications that can cause permanent damage or death. The patient and family should seek medical atention as soon as possible and not wait for other symptoms to appear.
Choice B: Return to hospital immediately for changes in level of consciousness is correct because it can also indicate worsening brain injury or complications from a head injury. Changes in level of consciousness can include confusion, drowsiness, agitation, or loss of awareness. The patient and family should monitor the patient's mental status and alertness and report any changes to the doctor.
Choice C: Call ambulance if unable to arouse patient is correct because it can mean that the patient has lost consciousness or is in a coma. This is a medical emergency that requires immediate intervention and resuscitation. The patient and family should not atempt to move or transport the patient by themselves but call for professional help.
Choice D: All of the above are correct because they are important instructions for the patient and family to follow when discharging patient home following a head injury. They can help prevent further harm or complications and ensure prompt treatment and recovery. The nurse should educate the patient and family about these instructions and provide them with writen information and contact numbers.
Correct Answer is D
Explanation
Choice A: Dark quiet room is correct, as it can reduce the sensory stimulation and help the patient relax and rest.
Choice B: Massage is correct, as it can relieve muscle tension and improve blood circulation in the head and neck.
Choice C: Pain medication is correct, as it can reduce inflammation and block pain signals in the brain.
Choice D: All of the above is correct, as all of these interventions can help manage headache.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today