An intoxicated client not wearing a seatbelt drives into a metal barricade near the entrance to the emergency department. The client's head has hit the windshield, and the client is unconscious. What nurse actions are appropriate? Select all that apply.

Question

Quizplus · Accepted Answer

11ecbb05_cb08_1e5e_b433_bbb9803ad00e_MD0009_00 The transference of kinetic energy to the client's body from an opposing force during sudden deceleration (eg, fall, motor vehicle collision) causes bodily injury. If the client is not wearing a seatbelt during an automobile crash, the client may strike (or be propelled through) the windshield, causing blunt-force trauma to the head, neck, or spine. The unconscious client should first be assessed for adequate breathing and the presence of a pulse (using the rule of airway, breathing, and circulation [ABCs]) (Option A). Using a rigid cervical collar, cervical spine immobilization must be maintained throughout the client assessment to minimize further injury (Option D). The client should be removed and placed on a backboard after the cervical spine has been stabilized (Option E). The nurse should also perform Glasgow Coma Scale scoring to determine the level of neurological impairment (Option B). (Option C) If a client with possible spinal injuries is not breathing, or if the airway is occluded, the nurse should use the jaw-thrust technique. The head-tilt/chin-lift maneuver may hyperextend the neck, compromising the cervical spine. Educational objective: After sudden deceleration with blunt-force head injury, the nurse first checks if the client is breathing and has a pulse (using the rule of airway, breathing, and circulation [ABCs]). Spinal injury should be presumed, and the cervical spine should be stabilized (eg, cervical collar). The jaw-thrust maneuver may be used to open the airway.

An Intoxicated Client Not Wearing a Seatbelt Drives into a Metal