During admission of a patient with a severe head injury to the ED, the nurse places highest priority on assessment for

• A. Presence of a neck injury
• B. Patency of airway
• C. Neurologic status with Glasgow Coma Scale
• D. CSF leakage from ears and nose

Answer: (B)

Ensuring an open airway is the highest priority because brain injury is worsened quickly by hypoxia. In a severe head injury, protecting and maintaining airway patency prevents reduced oxygen delivery to the brain, which can worsen cerebral edema and injury. Immediate actions focus on keeping the airway clear and facilitating ventilation, with cervical spine precautions as needed.

After the airway is secured, other assessments become important, but they do not outrank the need to breathe. Checking for a neck injury is essential for immobilization and spinal protection, and evaluating neurologic status with the Glasgow Coma Scale helps track brain function, but neither takes precedence over ensuring the patient can ventilate. CSF leakage signals a skull base fracture and potential complications, but it is not the immediate life threat compared to an unobstructed airway.