The emergency department nurse is assessing a client brought in after a car accident in which the client's head hit the steering column. Which assessment findings would indicate that the triage nurse should apply spinal immobilization? Select all that apply.

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11ecbb05_ca32_cc41_b433_b937d6a89b10_MD0009_00 Spinal immobilization is not a benign procedure. An acronym to help determine the need for spinal immobilization is NSAIDs: N - Neurological examination. Focal deficits include numbness and decreased strength. S - Significant traumatic mechanism of injury A - Alertness. The client may be disoriented or have an altered level of consciousness (Option B). I - Intoxication. The client could have impaired decision-making ability or lack awareness of pain (Option A). D - Distracting injury. Another significant injury could distract the client from spinal pain. S - Spinal examination. Point tenderness over the spine or neck pain on movement (if there is no midline tenderness) may be present (Option E). (Option C) The sensation of burning eyes could be related to many issues and does not necessarily have a direct correlation to spinal trauma. (Option D) There is no direct correlation of multiple sclerosis (autoimmune progressive nerve demyelinization) with the need for spinal immobilization. Educational objective: Indications for spinal immobilization include abnormal neurological findings, significant mechanism of injury, change in orientation or level of consciousness, intoxication, distracting injury, and point tenderness over the spine.

The Emergency Department Nurse Is Assessing a Client Brought in After