Difficulty: Medium
Average Score: 75%
Practice
A client who has a head injury is transported to the emergency department. Which assessment does the emergency department nurse perform immediately?
Correct answer
C
Rationale
In a client with a head injury, assessing the respiratory status is the priority as airway and breathing are essential for life. Immediate attention to respiratory status is crucial to ensure adequate oxygenation. While assessing pupil response and motor function are also important in head injuries, ensuring the client's ability to breathe takes precedence. Short-term memory assessment is not a priority in the emergent phase of care for a client with a head injury.