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 B
Explanation
Choice A: Pressure ulcer is not the most serious complication of a patient with altered level of consciousness, but rather a common and preventable complication that can cause skin breakdown, infection, and pain.
Choice B: Aspiration is the most serious complication of a patient with altered level of consciousness, as it can cause pneumonia, respiratory failure, and death.
Choice C: Contractures is not the most serious complication of a patient with altered level of consciousness, but rather a potential and reversible complication that can cause muscle stiffness, joint deformity, and reduced mobility.
Choice D: Deep vein thrombosis is not the most serious complication of a patient with altered level of consciousness, but rather a possible and treatable complication that can cause blood clots, swelling, and pain in the legs.
Correct Answer is C
Explanation
Choice A: Head of bed 45 degrees is not enough to prevent aspiration or choking, as the patient may still have difficulty swallowing and clearing their airway.
Choice B: Patient should be on a regular diet to rebuild their swallowing ability is not correct, as the patient may need a modified diet depending on their level of dysphagia or swallowing impairment. A regular diet may pose a risk of aspiration or choking.
Choice C: Have patient sit upright 90 degrees in bed or chair is correct, as this position helps the patient align their head and neck and use gravity to facilitate swallowing and prevent aspiration.
Choice D: All of the above is not correct, as only choice C is appropriate for assisting a stroke patient with feeding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today