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

A. Elevate the head of the bed 15 to 30 degrees with head maintained a midline position.

Correct Explanation: This intervention is appropriate for a child with an acute head injury.

Explanation: Elevating the head of the bed helps reduce intracranial pressure by facilitating venous drainage from the head. However, it's important to keep the head in a midline position to prevent neck flexion, which can obstruct venous flow. Elevating the head 15 to 30 degrees is a standard approach for managing intracranial pressure in patients with head injuries.

B. Maintain an active stimulating environment.

Incorrect Explanation: Maintaining an active stimulating environment is not suitable for a child with an acute head injury.

Explanation: A child with an acute head injury should be in a quiet and calm environment. Overstimulation can worsen the condition by increasing intracranial pressure. It's important to minimize stimuli to allow the brain to heal.

C. Perform active chest percussion and suctioning every 1 to 2 hours.

Incorrect Explanation: Chest percussion and suctioning are not relevant interventions for an acute head injury.

Explanation: Active chest percussion and suctioning are typically used to manage respiratory conditions. While maintaining good respiratory function is important for overall patient care, it's not a primary intervention for an unconscious child with a head injury.

D. Instruct child on performing active range of motion.

Incorrect Explanation: Instructing the child on performing active range of motion is not appropriate for an unconscious child with a head injury.

Explanation: An unconscious child cannot actively perform range of motion exercises. Additionally, it's not a priority intervention in the acute phase of head injury management.

A. Allow for adjustment of rules to correlate with the child's behavior.Rules should be consistent and predictable for children with ASD. Frequently changing or “adjusting” rules to match variable behavior increases confusion and anxiety and reduces opportunities to learn expected behaviors.

B. Allow for imaginative play with peers without supervision.
Many children with ASD need structured, supervised social interactions and support to learn play skills, take turns, and interpret social cues. Unsupervised imaginative play may lead to misunderstanding, frustration, or safety issues.

C. Provide a flexible schedule that adjusts to the child's interests.
While incorporating a child’s interests into activities is useful, children with ASD generally do best with a structured, predictable schedule. Sudden flexibility or frequent schedule changes can be disorienting. Best practice: keep a consistent routine but incorporate preferred interests within that structure.

D. Establish a reward system for positive behavior.A reward system (token economy, sticker charts, immediate specific praise) provides clear, consistent, and concrete reinforcement for targeted behaviors. This increases motivation, helps teach expected behaviors, and can be faded gradually as behaviors become routine.