Nursing Prioritization Delegation Assignment Q 85
A nurse enters a room and finds a patient lying face down on the floor and bleeding from a gash in the head. Which action should the nurse perform first?
A. Determine the level of consciousness
B. Push the call button for help
C. Turn the client face up to assess
D. Go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician
Correct Answer: A. Determine the level of consciousness.
Assessing the level of consciousness should be the first action when dealing with clients that might have fallen over. The initial step is to evaluate for reactivity using objective measures. Address the patient verbally, progress to light shaking, then progress to more intense mechanical stimulation.
Option B: After establishing the client’s ABCs, the nurse may call for help. The initial step in the evaluation of an unconscious patient is to evaluate for the basic signs of life. The American Heart Association recommends examining for a pulse, followed by assessing airway patency and breathing pattern.
Option C: Refrain from moving the patient until a physician comes into the scene and assesses the overall condition. For patients with a pulse, who are breathing adequately, the evaluation shifts to a detailed neurological examination. The neurologic examination would serve to determine the location and nature of the neurological lesion and to determine prognosis.
Option D: Do not leave the patient. A systematic evaluation of the unconscious patient is recommended. Because many cases of unconsciousness are reversible, the management of unconscious patients necessitates thorough history-taking, patient evaluation, stabilizing treatment, and diagnostic testing occurring simultaneously.