The nurse is caring for a child with Acute Renal Failure. Which clinical manifestation would the nurse recognize as a sign of hyperkalemia?

A. A client with suspected tuberculosis should be placed in a negative pressure room to prevent the spread of infection, not close to the nurses' station.

B. A client who sustained a head injury and is having periods of confusion requires close monitoring, especially to prevent falls or other safety concerns, making this room assignment the most appropriate.

C. A client with a severe migraine headache does not require continuous monitoring and can be placed in a quieter area away from the nurses' station.

D. A client on continuous ECG monitoring needs observation, but they do not require the most immediate attention or proximity to the nurses' station compared to a confused head injury client.

A. While the Babinski reflex can be assessed in older children, it is not an appropriate reflex to assess in an 11-month-old infant. Infants typically show a different reflex pattern, and the Babinski reflex may not provide meaningful insight in this age group. The focus should be on vital neurological signs like pupil reaction and fontanel assessment.

B. The infant's pupils should be regularly monitored for changes, as a decrease in pupil reaction or size could indicate increased intracranial pressure (ICP), which may be related to the subdural hematoma. This is a critical assessment to identify neurological changes.

C. The infant’s difficulty waking could indicate a change in neurological status, potentially due to increased ICP or other complications from the subdural hematoma. Feeding should not be encouraged until the infant is fully alert and stable to avoid the risk of aspiration or choking. Instead, the infant's neurological status should be assessed further.

D. In infants, the fontanels are a key indicator of increased intracranial pressure. A bulging fontanel can indicate rising ICP, which requires immediate intervention. This should be checked regularly in cases of head trauma.

E. Since the infant has fallen from a height (a flight of stairs), spine stabilization is necessary until spinal injury can be ruled out. The infant should be moved cautiously, and spine precautions should be maintained to prevent further injury.

F. Monitoring the head circumference is essential for detecting any signs of increased ICP. A sudden increase in head circumference may suggest worsening edema or hemorrhage, especially in the setting of a subdural hematoma.