# A nurse is conducting a primary assessment of a 35-year-old patient who arrives at the emergency department via ambulance following a high-speed motor vehicle collision. The patient is conscious but appears anxious and is complaining of chest pain. Which assessment should the nurse prioritize first?

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## 문제

A nurse is conducting a primary assessment of a 35-year-old patient who arrives at the emergency department via ambulance following a high-speed motor vehicle collision. The patient is conscious but appears anxious and is complaining of chest pain. 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 is complaining of chest pain.

## 보기

1. Check for signs of internal bleeding by assessing vital signs
2. Assess airway patency and breathing effectiveness **✔ 정답**
3. Evaluate neurological status using the Glasgow Coma Scale
4. Examine for obvious fractures and external injuries

**정답: 2**

## 해설

In emergency nursing, the primary assessment follows the ABCDE approach, with airway assessment as the first priority because airway obstruction can lead to death within minutes. Other options, such as checking for internal bleeding or evaluating neurological status, are important but secondary to ensuring airway patency and breathing effectiveness.

## 심화 해설

Primary Assessment in Trauma: The ABCDE Framework

The initial approach to any trauma patient follows a systematic, prioritized sequence known as the primary survey. This sequence is universally taught in trauma nursing core courses and is a foundational concept for the NCLEX-RN. The goal is to identify and manage the most immediate life-threatening conditions first. The established order is A (Airway with cervical spine protection), B (Breathing), C (Circulation), D (Disability/Neurological status), and E (Exposure/Environmental control).

The Guidelines for Essential Trauma Care emphasize that strengthening the organization of trauma care, which includes the systematic clinical assessment of injured patients, is fundamental to lowering mortality [1]. This structured approach ensures that physiological threats are addressed in order of lethality. A compromised airway or ineffective breathing will lead to death within minutes, preceding the consequences of circulatory collapse or neurological deterioration. Therefore, in a conscious patient complaining of chest pain after a high-speed collision, the nurse's immediate priority is to ensure that the airway is patent and that ventilation is adequate. Chest pain in this context could indicate a life-threatening injury such as a tension pneumothorax, massive hemothorax, or flail chest, all of which directly impair breathing and oxygenation.

While assessing for internal bleeding (option 1) and evaluating neurological status (option 3) are critical components of the primary survey, they fall under "C" (Circulation) and "D" (Disability), respectively. These steps are performed only after the airway and breathing have been assessed and stabilized. Examining for fractures and external injuries (option 4) is part of the secondary survey, which occurs after the primary survey is complete and the patient's immediate life threats have been addressed. The correct clinical decision-making process is to follow the A-B-C-D-E sequence without deviation, as this standardization is a core principle promoted by international trauma care guidelines to improve patient outcomes [1].

References (research sources)

- [1]Guidelines for Essential Trauma Care: Second Edition (2026).GuidelineMock C, Hardcastle TC, Gaarder C, Gupta A, Gyedu A, Joshipura M, Steyn E, Essential Trauma Care revision author group. (2026) · DOI: 10.1002/wjs.70321

## 임상 시나리오

Trauma Primary Survey: Airway FirstPrioritizing the ABCDE Sequence in the Emergency Department
The primary survey is a systematic assessment to find and treat the most lethal conditions first. The order is A (Airway with cervical spine protection), B (Breathing), C (Circulation), D (Disability), and E (Exposure). A compromised airway causes death in minutes, faster than circulatory or neurological failure.

For a conscious patient with chest pain after a high-speed collision, immediately assess airway patency and breathing effectiveness. Chest pain can signal a tension pneumothorax, massive hemothorax, or flail chest, which directly impair ventilation and oxygenation.

CautionDo not skip A and B to check vital signs or bleeding first. A patient who is talking has a patent airway, but you must still assess for potential obstruction or impending respiratory failure. Always assume a cervical spine injury in blunt trauma and maintain manual stabilization during the airway assessment.

## 핵심 개념

- **Primary Survey** — A systematic, rapid assessment using the ABCDE approach to identify and manage immediate life-threatening conditions in trauma patients.
- **ABCDE** — An acronym for the trauma assessment sequence: Airway, Breathing, Circulation, Disability, Exposure.
- **Tension Pneumothorax** — A life-threatening condition where air enters the pleural space and cannot escape, causing lung collapse and shifting of the heart and trachea.
- **Patent Airway** — An airway that is open and clear, allowing for effective passage of air into the lungs.
- **Cervical Spine Protection** — The practice of immobilizing the neck during airway assessment in trauma to prevent spinal cord injury from an unstable fracture.

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