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: Altered level of consciousness is not a sign/symptom of cerebral spinal fluid leakage, but rather a sign/symptom of increased intracranial pressure or brain injury.
Choice B: Painful headache is not a sign/symptom of cerebral spinal fluid leakage, but rather a sign/symptom of meningitis or sinusitis.
Choice C: Salty taste in their mouth, postnasal drip or clear fluid draining from the nose is a sign/symptom of cerebral spinal fluid leakage, as it indicates that the fluid is escaping from the brain or spinal cord through a tear or hole in the meninges or skull.
Choice D: All of the above is not correct, as only choice C is a sign/symptom of cerebral spinal fluid leakage.
Correct Answer is B
Explanation
Choice A: When patient is fully oriented is incorrect because it is a positive sign of recovery from a concussion. It means that the patient is aware of their person, place, time, and situation. The nurse should monitor the patient's orientation status but does not need to report it to the doctor immediately.
Choice B: Difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety are correct because they are signs of worsening brain injury or complications from a concussion. They may indicate increased intracranial pressure, bleeding, swelling, or infection in the brain. The nurse should report these symptoms to the doctor immediately and prepare for further diagnostic tests or interventions.
Choice C: When patient is easy to arouse is incorrect because it is also a positive sign of recovery from a concussion. It means that the patient responds quickly and appropriately to verbal or physical stimuli. The nurse should monitor the patient's level of consciousness but does not need to report it to the doctor immediately.
Choice D: All of the above are incorrect because only choice b) requires immediate reporting to the doctor. Choices a) and c) are normal or expected outcomes of a concussion and do not indicate any danger or complication. The nurse should use clinical judgment and follow the guidelines for concussion management and care.
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