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

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

Answer: (A)

Securing the airway is the priority because without a patent airway and adequate oxygenation, brain tissue cannot be perfused properly and secondary brain injury can quickly occur. In a severe head injury, consciousness is often depressed and facial injuries or secretions can easily compromise the airway and lead to hypoxia or aspiration. The nurse should first ensure a clear airway and provide oxygen, using suction and positioning as needed, and be prepared for advanced airway management with cervical spine protection if necessary. After the airway is stabilized, establishing a baseline neurologic status (such as the Glasgow Coma Scale) and assessing for other injuries becomes appropriate. Although neck injury assessment and CSF leakage are important, they do not pose as immediate a threat as an obstructed airway.