A client presents to the emergency department after falling down the stairs and has a suspected head injury. What is the nurse's priority once a patent airway is confirmed?

Clients with suspected head injuries from falls or trauma are at high risk for concurrent cervical spine injuries until proven otherwise. Trauma management follows the ABCs, with airway assessment first, but airway management must be performed while protecting the cervical spine. Movement of an unstable cervical spine can lead to spinal cord compression, permanent neurological damage, or respiratory failure. Preventing secondary injury is a major priority immediately after confirming airway patency. A. Establishing intravenous access with a large-bore catheter is important for fluid administration, medications, and emergency management, but it follows stabilization of airway and spinal protection. In trauma care, preventing further neurological injury takes precedence before additional interventions. IV access is necessary, but not before ensuring spinal precautions are maintained. B. Determining the presence of increased intracranial pressure is an important part of neurological assessment, especially in suspected traumatic brain injury. However, before detailed neurological evaluation, the nurse must ensure that no further cervical spine damage occurs. Assessment of ICP follows initial stabilization and protection of the spine. C. Maintaining cervical spine precautions is the priority because clients with head trauma may also have an unstable cervical spine injury. Even after confirming a patent airway, improper movement of the neck can cause spinal cord damage and irreversible paralysis. Immobilization devices should remain in place, and all care should be performed while preserving spinal alignment. D. Monitoring for changes in neurological status is essential for detecting deterioration in a client with head injury, but it is performed after immediate stabilization measures are secured. Protecting the cervical spine prevents catastrophic secondary injury, while neurological monitoring is an ongoing assessment that follows initial safety priorities.