Question

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?

A. Assess full ROM to determine extent of injuries.
B. Call for an immediate chest x-ray.
C. Immobilize the client's head and neck.
D. Open the airway with the head-tilt-chin-lift maneuver.

Answer 1

Assessing neurological function helps determine injury extent and prioritize interventions. Immobilizing the head and neck is the first nursing intervention in this case.

Step-by-step explanation:

A rapid assessment of neurological function is important in an emergency situation because it helps determine the extent of the patient's injury and enables healthcare providers to prioritize interventions. The initial assessment involves checking the patient's level of consciousness, orientation, and responsiveness. In this case, the first nursing intervention should be to immobilize the client's head and neck to prevent further damage or potential spinal cord injury.