53. What are the emergency nursing actions for a client with a head injury due to a fall from a third-floor roof?
53. What are the emergency nursing actions for a client with a head injury due to a fall from a third-floor roof?
. Assess respirations, assess circulation, and assess level of consciousness.
. Stabilize C-spine, determine responsiveness, and begin chest compressions.
. Stabilize C-spine, assess airway, and assess respirations.
. Assess airway, assess respirations, and assess circulation.
Test-Taking Tip
Whenever there is a possibility of neck injury, stabilize the neck before checking the ABCs.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Implementation; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Medical Emergencies
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Answer 1 is incorrect because this choice does not immobilize the client's neck. Answer 2 is incorrect because, after immobilizing the spine, determining responsiveness would be the next priority. Answer 3 is correct because, before assessing the CABs (compression, airway, and breathing) in this client, it is important to prevent further injury to the spinal cord. Answer 4 is incorrect because this choice does not stabilize the spine.