Question

After an automobile collision, a client who sustained multiple injuries is oriented to person and place but is confused to time. The client complains of a headache and drowsiness, but assessment reveals that the pupils are equal and reactive. Which nursing action takes priority?

Answer 1

Answer:

The best answer to the question: Which nursing action takes priority, when talking about a patient who was on an automobile collision and who sustained multiple injuries, would be: Maintain constant observation and monitoring of appearance of possible signs and symptoms of increased intracraneal pressure.

Explanation:

The reason for this being the correct nursing plan for the patient comes from the evidence present in the patient himself. He has been through an automobile accident in which without much doubt, his head was hit. Because he is presenting mild symptoms of neurological affectation, like drowsiness, headache and also disorientation in time, only, this indicates that it is a possibility that intracraneal pressure may be affected, or may be affected in the future. Thus, the nurse will strive to evaluate the patient´s responsiveness to certain stimulus like periodical conversation, preventing the patient from falling asleep but allowing him to stay silent through intervals. In this way the nurse will effectively monitor and observe the patient for any signs that may indicate a change in intracraneal pressure.