# A nurse is conducting a primary assessment of an elderly patient who arrives at the emergency department following a motor vehicle accident. Which assessment should the nurse prioritize first?

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## 문제

A nurse is conducting a primary assessment of an elderly patient who arrives at the emergency department following a motor vehicle accident. Which assessment should the nurse prioritize first?

A 35-year-old patient arrives at the emergency department via ambulance following a high-speed motor vehicle collision. The patient is conscious but appears anxious and restless.

## 보기

1. Check for neurological deficits and pupil response
2. Assess for internal bleeding and abdominal injuries
3. Evaluate extremities for fractures and dislocations
4. Establish airway patency and breathing adequacy **✔ 정답**

**정답: 4**

## 해설

In emergency nursing, the primary assessment follows the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure). Airway and breathing assessment must be prioritized first as they are immediately life-threatening if compromised.

In emergency nursing, the primary assessment follows the ABCDE approach (airway, breathing, circulation, disability, exposure). This prioritization is based on the principle that certain conditions are immediately life-threatening and require immediate intervention.

Airway obstruction can cause death within minutes, making it the top priority in all emergency assessments. Even if the patient is conscious and able to speak, the airway can become blocked due to trauma, swelling, foreign objects, or loss of consciousness. In a traffic accident patient, the airway may be obstructed due to facial trauma, cervical spine injury, or the risk of aspirating blood or vomit.

Breathing assessment is performed immediately after airway assessment because adequate ventilation is essential for oxygenation. Trauma patients can deteriorate rapidly from pneumothorax, hemothorax, rib fractures, or other respiratory injuries. Nurses must assess respiratory rate, depth, symmetry of chest movement, and oxygen saturation.

Neurological assessment, evaluation of internal bleeding, and limb examination are all important components of trauma assessment, but they follow the ABC priority. A patient cannot survive without a patent airway and adequate breathing, regardless of other injuries. This systematic approach identifies and treats life-threatening conditions according to priority, maximizing the patient's chance of survival.

## 심화 해설

Primary Assessment in Trauma: The ABCs

In emergency nursing, clinical reasoning is a core competence that directly impacts patient safety and outcomes, particularly when managing trauma patients with rapidly evolving conditions [1]. The scenario describes a conscious but anxious and restless patient following a high-speed collision. This presentation should immediately raise concern for a physiological insult such as hypoxia or shock, which requires a structured, priority-driven assessment.

The foundational framework for any trauma patient is the primary survey, organized by the mnemonic ABCDE: Airway with cervical spine protection, Breathing, Circulation, Disability, and Exposure. This sequence is designed to identify and manage the most life-threatening conditions first. The nurse's ability to discern the severity of a clinical situation and intervene effectively, as highlighted in the context of emergency department clinical reasoning, begins with this systematic approach [1].

Among the options provided, establishing airway patency and breathing adequacy is the correct priority. The physiological rationale is straightforward: without a patent airway and effective ventilation, irreversible brain damage and cardiac arrest occur within minutes. The patient's restlessness and anxiety can be an early and critical sign of hypoxemia, which must be ruled out before moving to other assessments. A compromised airway or inadequate breathing is an immediate threat to life and takes absolute precedence over a neurological examination, assessment for internal bleeding, or evaluation for fractures.

To clarify why the other options are secondary, consider the clinical reasoning process in the context of the ABCDE hierarchy:

| Assessment Option | ABCDE Stage | Rationale for Not Being the First Priority |
| --- | --- | --- |
| 1. Check for neurological deficits and pupil response | D (Disability) | A neurological assessment is a crucial component of the primary survey, but it follows the stabilization of airway, breathing, and circulation. A brain injury cannot be effectively managed if the patient is not being oxygenated or perfused. |
| 2. Assess for internal bleeding and abdominal injuries | C (Circulation) | While a high-speed mechanism raises a high index of suspicion for internal hemorrhage, the "C" assessment for circulation begins only after the "A" and "B" are addressed. The most immediate way to improve oxygen delivery to tissues is to ensure the oxygen is entering the body first. |
| 3. Evaluate extremities for fractures and dislocations | E (Exposure) | Musculoskeletal injuries are rarely an immediate threat to life unless they involve major hemorrhage or compromise the airway (e.g., a cervical spine injury). This assessment is part of the secondary survey and is performed after the primary survey is complete and life threats are managed. |

The nurse's clinical reasoning in this scenario involves recognizing that restlessness is a classic sign of respiratory distress. By immediately assessing the airway and breathing, the nurse is not just following a protocol but actively anticipating a potential complication—respiratory failure—and intervening to prevent the patient's clinical deterioration [1]. This demonstrates the rapid discernment of severity that is essential for competent emergency nursing practice.

References (research sources)

- [1]Nurses' Clinical Reasoning Process: A Grounded Theory Study.Research articleMendonça S. (2026) · DOI: 10.3390/healthcare14020230

## 임상 시나리오

Clinical Practice Guide: Trauma Primary Assessment

The ABCDE Approach

The primary survey is a systematic, non-negotiable sequence designed to find and fix the most lethal problems first. Deviating from this order risks missing a rapidly fatal condition. The components are:

- **A - Airway with C-spine protection:** Assess patency. Is the patient talking? Are there gurgling sounds, stridor, or obstruction? If the airway is compromised, immediate interventions like a jaw-thrust maneuver, suctioning, or definitive airway placement are required. Assume a cervical spine injury in blunt trauma until cleared.

- **B - Breathing:** Evaluate ventilation and oxygenation. Look, listen, and feel for chest rise, respiratory rate, depth, and breath sounds. Identify life-threats like tension pneumothorax, massive hemothorax, or flail chest. Administer high-flow oxygen.

- **C - Circulation:** Assess for shock. Check pulse rate and quality, skin color and temperature, and capillary refill. Control external hemorrhage with direct pressure. Establish large-bore IV access and begin fluid resuscitation.

- **D - Disability:** Perform a rapid neurological assessment (Glasgow Coma Scale, pupil reactivity). This establishes a baseline and identifies intracranial catastrophe.

- **E - Exposure:** Completely undress the patient to identify all injuries while preventing hypothermia with warm blankets and fluids.

Clinical Pearl: Restlessness as Hypoxia

An anxious, restless patient in trauma should be assumed to be hypoxic until proven otherwise. This is a cardinal sign of inadequate oxygenation and must trigger an immediate reassessment of Airway and Breathing. Never attribute this solely to pain or fear without ruling out a physiological cause.

## 핵심 개념

- **Primary Survey** — A systematic, rapid assessment using the ABCDE approach to identify and manage immediate life-threatening conditions in a trauma patient.
- **ABCDE** — A mnemonic for trauma assessment sequence: Airway with c-spine protection, Breathing, Circulation, Disability, Exposure.
- **Hypoxemia** — An abnormally low concentration of oxygen in the blood, which can manifest as restlessness and anxiety.

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