A patient with suspected spinal cord and head injuries is brought into the emergency department on a backboard after a car accident
The Glasgow Coma Scale score is 15; vital signs are blood pressure 130/82 mm Hg, pulse 102 beats/min, respirations 20 breaths/min, and temperature 98°F (36.6°C). What is the most important nursing intervention during initial care of the patient?
a. Check the extremities for range of motion.
b. Avoid moving the patient.
c. Turn the patient to the side to avoid aspiration.
d. Keep the head of the bed elevated 30 degrees.
ANS: B
The first priority is prevention of further spinal cord injury, so the patient must be kept flat without movement of the trunk. Checking range of motion, turning, or elevating the head could cause further injury.
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