When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management once a patent airway is confirmed is

When a patient is admitted to the emergency department following a head injury, the nurse's first priority in management once a patent airway is confirmed is

• A. Determining the presence of increased ICP
• B. Monitoring for changes in neurologic status
• C. Establishing IV access with a large-bore catheter
• D. Maintaining cervical spine precautions

Answer: (D)

Protecting the spine is the immediate priority after airway is secure because a cervical spine injury may be present and movement can worsen—or cause irreversible—neuro damage. In a head trauma patient, you immobilize the cervical spine with a collar and secure the patient to a backboard, maintaining neutral alignment and avoiding any flexion, extension, or rotation during assessment and transport. This step, done upfront, prevents secondary spinal injury even as you continue to monitor airway, breathing, and circulation. Other priorities—like assessing for increased intracranial pressure, watching for neurologic changes, or establishing IV access—remain important but are addressed after spine precautions. Keeping the neck stabilized ensures you don’t compound injuries while you perform these other assessments and interventions.

Protecting the spine is the immediate priority after airway is secure because a cervical spine injury may be present and movement can worsen—or cause irreversible—neuro damage. In a head trauma patient, you immobilize the cervical spine with a collar and secure the patient to a backboard, maintaining neutral alignment and avoiding any flexion, extension, or rotation during assessment and transport. This step, done upfront, prevents secondary spinal injury even as you continue to monitor airway, breathing, and circulation.

Other priorities—like assessing for increased intracranial pressure, watching for neurologic changes, or establishing IV access—remain important but are addressed after spine precautions. Keeping the neck stabilized ensures you don’t compound injuries while you perform these other assessments and interventions.