Nursing Prioritization Delegation Assignment Q 6
What is regarded as one of the priority actions that must be accomplished when a primary assessment of a trauma client is conveyed?
A. Taking a full set of vital sign measurements.
B. Completing a brief neurologic assessment.
C. Monitoring pulse oximetry reading.
D. Palpating and auscultating the abdomen.
Correct Answer: B. Completing a brief neurological assessment
A brief neurologic assessment to ascertain level of consciousness and pupil reaction is part of the primary survey. Once the patient is stabilized, a neurologic examination should be conducted. CT scan is the diagnostic modality of choice in the initial evaluation of patients with head trauma.
Option A: Vital signs are considered part of the secondary survey. Avoid hypotension. Normal blood pressure may not be adequate to maintain adequate flow and CPP if ICP is elevated. Isolated head trauma usually does not cause hypotension. Look for another cause if the patient is in shock.
Option C: Identify any condition which might compromise the airway, such as pneumothorax. The cervical spine should be maintained in-line during intubation. Nasotracheal intubation should be avoided in patients with facial trauma or basilar skull fracture.
Option D: Assessment of abdomen is basically part of the secondary survey. The secondary survey is a rapid but thorough head to toe examination assessment to identify potential injuries. It should be performed after the primary survey and the initial stabilization is complete.