# A nurse is caring for an unconscious client who was admitted following a traumatic brain injury. Which nursing intervention is the PRIORITY to prevent complications in this client?

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> subject: Adult Health

## 문제

A nurse is caring for an unconscious client who was admitted following a traumatic brain injury. Which nursing intervention is the PRIORITY to prevent complications in this client?

## 보기

1. Perform passive range-of-motion exercises every 2 hours
2. Maintain patent airway and monitor respiratory status continuously **✔ 정답**
3. Turn the client every 2 hours to prevent pressure ulcers
4. Insert a urinary catheter to monitor fluid balance

**정답: 2**

## 해설

Maintaining airway patency and respiratory monitoring is the priority for unconscious clients due to compromised protective reflexes and high risk of airway obstruction. Other interventions like ROM exercises and turning are important but secondary to immediate life-threatening risks.

## 심화 해설

Understanding the Priority: Airway Management in Traumatic Brain Injury

The foundation of trauma care rests on a systematic approach, and for an unconscious client with a traumatic brain injury (TBI), the immediate and overarching priority is ensuring a patent airway and adequate ventilation. This principle is embedded in the globally recognized Essential Trauma Care guidelines, which emphasize that strengthening the organization of trauma care, starting with the most fundamental life-saving interventions, is critical to lowering mortality [2]. The rationale is rooted in pathophysiology: an unconscious patient loses protective airway reflexes, placing them at high risk for airway obstruction from the tongue, secretions, or aspiration. More critically, a TBI directly compromises the brain's respiratory centers, and post-traumatic apnoea is a major and potentially reversible contributor to early mortality, which can rapidly lead to hypoxic injury and death [3].

The clinical cascade is swift and devastating. An obstructed airway or respiratory depression leads to hypoxia and hypercapnia. For the injured brain, these are catastrophic secondary insults. Hypoxia deprives vulnerable neurons of oxygen, exacerbating the primary injury, while hypercapnia causes cerebral vasodilation, increasing cerebral blood volume and subsequently elevating intracranial pressure (ICP). This rise in ICP can further compromise cerebral perfusion pressure (CPP), creating a vicious cycle of worsening brain injury. Therefore, the intervention of maintaining a patent airway and continuously monitoring respiratory status is not merely a supportive measure; it is a direct, therapeutic action to prevent these secondary brain injuries [3].

While other interventions are important components of holistic care, they are secondary to airway and breathing. Turning the client to prevent pressure ulcers and performing passive range-of-motion exercises are crucial for long-term complication prevention but do not address an immediate threat to life. Inserting a urinary catheter for strict fluid balance monitoring is a valuable tool in managing a neurocritical care patient, particularly when therapies like targeted temperature management are employed . However, accurate output monitoring is irrelevant if the patient is not adequately oxygenating and ventilating. The nursing process mandates a hierarchy of needs based on threat to life, and in the unconscious TBI patient, a compromised airway is the most immediate lethal threat, making its management the absolute priority.References (research sources)

- [2]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

- [3]Managing apnoea in trauma victims: the potential for dispatcher-assisted airway handling - a narrative review.Research articleImbriaco G, D'arrigo S, Limonti F, Rehn M, Cucino A. (2025) · DOI: 10.1186/s13049-025-01533-w

## 임상 시나리오

Airway Priority in Unconscious TBIApplying the ABCs to Prevent Secondary Brain Injury
In any unconscious patient with a traumatic brain injury, the immediate priority is to secure and maintain a patent airway. Loss of protective reflexes leads to a high risk of obstruction and aspiration.

A compromised airway causes hypoxia and hypercapnia. Hypercapnia induces cerebral vasodilation, which increases intracranial pressure (ICP) and reduces cerebral perfusion pressure (CPP), worsening the secondary brain injury.

CautionDo not delay airway management for other interventions. Continuous monitoring of respiratory rate, pattern, SpO2, and end-tidal CO2 is essential to detect early deterioration and prevent irreversible hypoxic damage.

## 핵심 개념

- **Airway Management** — Airway management. This refers to a series of interventions (such as positioning, suctioning, use of airway maintenance devices, etc.) to maintain airway patency and ensure adequate ventilation in patients who are unconscious or experiencing respiratory distress.
- **Traumatic Brain Injury** — Traumatic brain injury. A condition where brain function is damaged by external physical force, which can cause changes in consciousness level, cognitive impairment, motor/sensory disorders, etc.
- **Respiratory Compromise** — Respiratory impairment. This refers to a condition where respiratory function is insufficient, failing to supply oxygen to tissues and remove carbon dioxide, and it may progress to respiratory failure.
- **Aspiration** — Aspiration. This refers to the entry of oral or gastric contents into the airway and lungs, with a high risk of occurrence in unconscious patients due to reduced cough reflex, and it can cause aspiration pneumonia.
- **Neurological Assessment** — Neurological assessment. A comprehensive evaluation including level of consciousness (GCS), pupillary response, motor response, and vital signs, essential for monitoring brain function and potential complications (such as increased intracranial pressure), especially in TBI patients.

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