A nurse is caring for a 13-year-old adolescent in the pediatric emergency room who has a suspected head injury. Which of the following actions should the nurse take first?
Explanation & Rationale
A. Notify the adolescent's primary care provider is incorrect. While it is important to notify the healthcare provider, the immediate priority is performing a thorough assessment to determine the severity of the head injury and any potential complications, such as changes in consciousness or neurological status. B. Collect a detailed past medical history is incorrect. Although collecting medical history is important, it is not the priority in the acute phase of a suspected head injury. The priority is to assess the current condition of the adolescent, especially signs of deterioration. C. Perform a thorough assessment noting acute conditions is correct. The priority in suspected head injuries is to perform a thorough assessment to evaluate the patient's neurological status. This includes checking for signs of a concussion, increased intracranial pressure, or any other acute conditions that may require immediate intervention. D. Administer pain medication to the adolescent is incorrect. Pain management is important, but it should not be the first action when a head injury is suspected, as it can mask symptoms or affect the ability to assess neurological function properly.