The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first?
A) The client with an open head injury
B) The client with a basilar fracture
C) The client with a concussion
D) The client with a coup injury
B
Feedback:
Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.
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