A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first?
Assess full ROM to determine extent of injuries
Call for an immediate chest x-ray
Immobilize the client’s head and neck
Open the airway with the head-tilt-chin-lift maneuver
All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn’t need to be opened since the client appears alert and not in respiratory distress.

Option A: ROM would be contraindicated at this time.
Option B: There is no indication that the client needs a chest x-ray.
Option D: In addition, the head-tilt-chin-lift manoeuvre wouldn’t be used until the cervical spine injury is ruled out.