After the emergency department nurse has received a status report on the following patients who have been admitted with head injuries, which patient should the nurse assess first?
a. A 20-year-old patient whose cranial x-ray shows a linear skull fracture
b. A 30-year-old patient who has an initial Glasgow Coma Scale score of 13
c. A 40-year-old patient who lost conscious-ness for a few seconds after a fall
d. A 50-year-old patient whose right pupil is 10 mm and unresponsive to light
ANS: D
The dilated and nonresponsive pupil may indicate an intracerebral hemorrhage and increased in-tracranial pressure. The other patients are not at immediate risk for complications such as herni-ation.
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