A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy.
Which of the following actions should the nurse include in the plan of care?

Choice A rationale:

Assess respiratory status. In a child with a head injury, assessing respiratory status is the top priority. Respiratory distress or compromise could indicate potential brain injury or other serious complications. Ensuring an open airway, adequate breathing, and proper oxygenation is essential for the child's immediate well-being. Any signs of respiratory distress should be promptly addressed to prevent further complications.

Choice B rationale:

Check pupil reactions. Checking pupil reactions is important in assessing neurological function, but it is secondary to assessing respiratory status in this scenario. Respiratory status takes precedence because impaired breathing can lead to hypoxia, which can further compromise neurological function. Once respiratory status is stabilized, assessing neurological signs, including pupil reactions, becomes crucial to evaluate potential brain injury.

Choice C rationale:

Inspect for fluid leaking from the ears. Inspecting for fluid leaking from the ears is important in head injury assessment, specifically for signs of cerebrospinal fluid leakage. However, it is not the first action to take. Assessing respiratory status and ensuring proper oxygenation are immediate

The correct answer is choice d. Demonstrate deep-breathing and counting exercises.

Choice A rationale:

Using vague language to describe the procedure can increase anxiety and fear in the child. Clear and age-appropriate explanations help the child understand what to expect.

Choice B rationale:

A 30-minute teaching session may be too long for a school-age child, leading to loss of attention and increased anxiety. Short, focused sessions are more effective.

Choice C rationale:

Explaining the procedure in the playroom can associate a place of comfort with stress and anxiety. It’s better to explain the procedure in a neutral or medical setting.

Choice D rationale:

Demonstrating deep-breathing and counting exercises helps the child manage anxiety and pain during the procedure. These techniques are effective coping strategies for children undergoing medical procedures.