The nurse admits a client who fell off a 20-ft (6-m) ladder. On arrival in the emergency department, the client is arousable but lethargic. What is the nurse's priority action?

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11ecbb05_ca3e_3dfb_b433_9bcbaf3d9236_MD0009_00 After trauma to a client (eg, fall), the nurse performs an emergency or trauma assessment that includes a primary and secondary survey (assessment). The primary assessment determines the status of the airway, breathing, and circulation (ABCs). Next, the nurse evaluates disability (D) of neurological function using the Glasgow Coma Scale (GCS). The GCS measures the client's level of consciousness by assessing the best eye opening response, best verbal response, and best motor response. The lower the GCS score, the higher the risk for the client to develop complications (eg, loss of airway patency, increased intracranial pressure). (Options A, B, and D) Although a health history, head-to-toe assessment, and notation of the client's level of pain are essential for the overall assessment, they are considered part of the secondary survey. This survey's purpose is to get a complete picture of the injuries, but only after the client's priority needs have been addressed. Educational objective: After trauma to a client (eg, fall), the nurse performs a primary survey to determine status of airway, breathing, circulation, disability (eg, Glasgow Coma Scale to assess neurological impairment), and exposure. Health history, head-to-toe assessment, and level of pain are part of the secondary survey.

The Nurse Admits a Client Who Fell Off a 20-Ft