A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

Choice A reason:
While memory lapses, such as being unable to remember their adult children's names, can be concerning, they are not the immediate priority following a head injury. Memory issues may result from various factors, including the emotional shock of the fall or pre-existing cognitive conditions.

Choice B reason:
The inability to remain fully awake, or altered levels of consciousness, is a critical sign that may indicate a serious brain injury, such as a concussion or hemorrhage. This finding requires urgent attention to prevent further complications, making it the nurse's priority.

Choice C reason:
Difficulty in repeating the names of three common objects could suggest cognitive impairment or confusion, which are concerning but secondary to consciousness and alertness issues. Cognitive assessments are part of a broader neurological evaluation following a head injury.

Choice D reason:
Incorrectly answering a judgment question is part of a cognitive assessment and, while important, does not take precedence over signs that may indicate a life-threatening condition, such as changes in consciousness.

Choice A Reason:
Activating the fire alarm system is an important step in the event of a fire, as it alerts other staff and triggers emergency protocols. However, the immediate priority is the safety of the client. The nurse should ensure that the client is out of harm's way before activating the alarm.

Choice B Reason:
Using a fire extinguisher at the source of the smoke may be necessary if the fire is small and contained, and if the nurse is trained to do so. However, this action should only be taken after ensuring the client's safety and if it does not pose a risk to the nurse or the client.

Choice C Reason:
Closing the doors to the room and to the bathroom can help contain the smoke and prevent the spread of fire. This is a critical step, but it is not the first action the nurse should take. The nurse's first responsibility is to the safety and well-being of the client.

Choice D Reason:
The first action the nurse should take is to assist the client to a nearby common area, away from the source of the smoke. This aligns with the RACE acronym (Rescue, Alarm, Contain, Extinguish) used in fire safety, which prioritizes removing anyone in immediate danger.