A patient with suspected spinal cord and head injuries has a Glasgow Coma Scale score of 15; 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 the initial care of the patient?
a. Avoid moving the patient.
b. Check the extremities for range of motion.
c. Turn the patient to the side to avoid aspiration.
d. Keep the head of the bed elevated 30 degrees.
ANS: A
The first priority is prevention of further spinal cord injury, so the patient must be kept flat without movement of the trunk. B. C. D. Checking range of motion, turning, or elevating the head could cause further injury.
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