Which of the following causes skin breakdown?

Choice A: Nutrition supplements is not a direct intervention for maintaining skin integrity, but rather a general measure to support the patient's overall health and healing.

Choice B: Consulting speech therapy is not relevant for maintaining skin integrity, but rather for addressing the patient's communication and swallowing needs.

Choice C: Assessing the skin and frequent repositioning is a correct intervention for maintaining skin integrity, as it can prevent pressure ulcers or bedsores by reducing friction, shear, and moisture on the skin.

Choice D: Ambulating the patient as much as possible is not a specific intervention for maintaining skin integrity, but rather a general measure to promote the patient's mobility and circulation.

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.