A head-injured patient becomes less responsive, vomits repeatedly and develops unequal pupils. Which action should the nurse take first?
Correct answer: B. Elevate the head, maintain airway support and notify the emergency team
- A. Place the patient flat and encourage oral fluids
- B. Elevate the head, maintain airway support and notify the emergency team
- C. Give a sedative and dim the room lights
- D. Perform repeated deep suctioning to stimulate consciousness
Explanation
Reduced consciousness, vomiting and unequal pupils may indicate rising intracranial pressure with possible herniation. Airway support and head elevation help protect breathing and venous drainage while urgent medical review is obtained; oral fluids and unnecessary stimulation are unsafe.
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About Critical Care and Emergency Nursing
Covers rapid assessment and stabilisation of patients with airway obstruction, respiratory failure, shock, cardiac arrest, sepsis, poisoning and major electrolyte disturbances. It includes triage, the ABCDE approach, cardiopulmonary resuscitation, ventilator and monitor care, emergency medicines and distinguishing life-threatening deterioration from stable illness.
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