A nurse is creating a plan of care for a child who is awake and responsive following an acute head injury. Which of the following interventions should the nurse include?

Place the child in a room with bright fluorescent lighting.

Initiate seizure precautions for the child.

Use the COMFORT scale to rate the child's pain.

Suction the child's nares to determine the presence of fluid.

Answer and Explanation

The Correct Answer is B

A. Place the child in a room with bright fluorescent lighting.

This option is not appropriate because bright fluorescent lighting can be uncomfortable and potentially aggravate symptoms such as headache or sensitivity to light, which are common after a head injury. Therefore, it is not included in the plan of care.

B. Initiate seizure precautions for the child.

This intervention is appropriate because children with head injuries are at an increased risk of seizures. Seizure precautions may include ensuring a safe environment, such as padding the sides of the bed, removing any objects that could cause harm during a seizure, and closely monitoring the child's neurological status for signs of seizure activity.

C. Use the COMFORT scale to rate the child's pain.

While assessing and managing pain is important, the COMFORT scale may not be the most appropriate tool for evaluating pain in a child with a head injury. The nurse should use a pain assessment tool that is specifically designed for pediatric patients and is suitable for assessing pain in children with head injuries.

D. Suction the child's nares to determine the presence of fluid.

Suctioning the child's nares may be indicated if there are concerns about airway patency or respiratory secretions. However, it is not a routine intervention for all children with head injuries. The nurse should assess the child's respiratory status and use suctioning only if necessary based on clinical findings.

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Correct Answer is A

Explanation

A. Report of diplopia

Diplopia, or double vision, can be a symptom of increased intracranial pressure (ICP) due to its effects on cranial nerve function. Therefore, it is a manifestation that the nurse should recognize as indicating the presence of increased ICP.

B. Hyperactivity

Hyperactivity is not typically associated with increased ICP. Instead, manifestations of increased ICP often include altered level of consciousness, lethargy, or even coma.

C. Nuchal rigidity

Nuchal rigidity, or stiffness in the neck, is not a direct manifestation of increased ICP. It is more commonly associated with meningitis or other conditions affecting the meninges.

D. Report of sore throat

A sore throat is not typically associated with increased ICP unless it is related to complications such as pharyngeal injury or infection.

A. A child who is postoperative following a tonsillectomy and reports moderate throat pain B. A child who had a cardiac catheterization using the femoral artery and has blanching of the toes C. A child who has bacterial pneumonia and is due for their initial dose of IV antibiotics D. A child who has juvenile idiopathic arthritis and needs assistance with application of prescribed splints

Correct Answer is B

Explanation

A. A child who is postoperative following a tonsillectomy and reports moderate throat pain.

While postoperative pain management is important, moderate throat pain in a child who has undergone a tonsillectomy is expected. This client's condition is stable, and their pain can be managed with appropriate interventions. It is not the most urgent situation among the options provided.

B. A child who had a cardiac catheterization using the femoral artery and has blanching of the toes.

Blanching of the toes following a cardiac catheterization using the femoral artery can indicate compromised circulation, potentially leading to ischemia or necrosis. This requires immediate assessment to prevent further complications.

C. A child who has bacterial pneumonia and is due for their initial dose of IV antibiotics.

While timely administration of antibiotics is important in the treatment of bacterial pneumonia, missing the initial dose by a short period of time is not likely to result in significant harm compared to a potential circulatory compromise in option B.

D. A child who has juvenile idiopathic arthritis and needs assistance with the application of prescribed splints.

While providing assistance with splint application is necessary for comfort and mobility, it is not as urgent as assessing potential circulatory compromise or initiating antibiotic therapy for pneumonia.

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