The nurse is caring for a 10-year-old child who has an acute head injury, has a pediatric Glasgow Coma Scale score of 9, and is unconscious. What intervention should the nurse include in the child's care plan?

Choice A reason: A patient-controlled analgesia pump delivers opioids for effective pain management post-scoliosis repair, a major surgery causing significant discomfort. Controlling pain reduces stress, promotes mobility, and supports healing by allowing the adolescent to participate in physical therapy without excessive pain hindering recovery.

Choice B reason: Log rolling every 4 hours is insufficient; post-scoliosis surgery patients require more frequent repositioning (every 2 hours) to prevent pressure ulcers. Log rolling maintains spinal alignment, but the timing is critical to avoid skin breakdown, making this intervention partially correct but suboptimal.

Choice C reason: Protective isolation is unnecessary post-scoliosis repair, as the procedure does not inherently increase infection risk requiring isolation. Standard precautions suffice, and isolation could hinder psychological recovery by limiting social interaction, which is important for adolescents post-surgery.

Choice D reason: A 30-degree head elevation is not standard post-scoliosis repair, as patients typically remain flat to maintain spinal alignment with Harrington rods. Elevation may strain the surgical site, risking rod displacement or delayed healing, making this intervention inappropriate for postoperative care.

Choice A reason: Increased sleeping, or lethargy, indicates increased intracranial pressure in infants, as pressure on brain structures impairs arousal. Cerebral edema or fluid buildup reduces consciousness, a critical neurological sign requiring urgent evaluation to prevent brain herniation or permanent damage.

Choice B reason: A high-pitched cry is a sign of increased intracranial pressure in infants, reflecting neurological irritation from pressure on brain structures. This abnormal cry results from central nervous system stress, distinguishing it from normal crying and indicating a need for immediate medical attention.

Choice C reason: The setting sun sign, where eyes appear downward with sclera visible above, indicates increased intracranial pressure in infants. Pressure on cranial nerves affects eye movement, causing this characteristic sign, a key indicator of neurological compromise requiring urgent intervention.

Choice D reason: Decreased head circumference is not associated with increased intracranial pressure. Pressure causes bulging fontanels or increased head size in infants due to fluid or blood accumulation, making this an incorrect sign, as it suggests dehydration or microcephaly instead.

Choice E reason: Increased appetite is not a sign of increased intracranial pressure. Pressure typically causes lethargy or poor feeding due to neurological compromise, not increased hunger. Appetite changes are unrelated to the cerebral effects of elevated intracranial pressure in infants.