A patient with a head injury becomes increasingly drowsy and vomits twice. The patient now responds only to repeated verbal stimulation. What is the nurse's priority action?
Correct answer: B. Assess airway and breathing while calling for urgent help
- A. Place the patient flat and leave the room briefly
- B. Assess airway and breathing while calling for urgent help
- C. Give an oral antiemetic with a sip of water
- D. Allow the patient to sleep without further observations
Explanation
Increasing drowsiness and repeated vomiting may indicate worsening intracranial pressure and loss of airway protection. The nurse must assess airway and breathing and summon urgent help, while avoiding oral medication in a patient with reduced consciousness.
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About Clinical Judgement and Prioritisation
Clinical judgement links assessment findings, nursing knowledge and patient responses to a safe decision. Coverage includes ABCDE assessment, recognising actual or potential instability, prioritising airway, breathing and circulation, using urgency and risk rather than routine order, reassessing after intervention, and distinguishing a nursing priority from a medical diagnosis or a task that can wait.
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