After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client’s immediate needs

After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client’s immediate needs, then prepares to perform a neurologic assessment. Because the client is unstable and in critical condition, this examination must be brief but should include:
a. Evaluation of the corneal reflex response
b. Examination of the fundus of the eye
c. Assessment of the client’s gait
d. Evaluation of bowel and bladder functions

Answer A. During an acute crisis, the examiner checks the corneal reflex response to rapidly assess brain stem function.
Other components of the brief initial neurologic assessment usually include level of consciousness, pupillary response, and motor response in all arms and legs.
If appropriate and if time permits, the nurse also may assess sensory responses of the arms and legs.
Emergency assessment doesn’t include fundus examination unless the client has sustained direct eye trauma.
The client shouldn’t be moved unnecessarily until the extent of injuries is known, making gait evaluation impossible.
Bowel and bladder functions aren’t vital, so the nurse should delay their assessment.