While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

In an infant, a bulging fontanel is a classic sign of increased intracranial pressure. The fontanel, or soft spot on the top of the skull, can bulge when there is a buildup of pressure inside the skull, often due to conditions like hydrocephalus or complications with a ventriculoperitoneal shunt.

Preparing for a CT scan is crucial for diagnosing underlying causes of increased intracranial pressure, which could be related to shunt issues or other intracranial abnormalities.

Implementing seizure precautions ensures safety and readiness for possible seizures due to elevated intracranial pressure.

Monitoring pupil size helps assess neurological status and detect signs of increased intracranial pressure.

Tracking heart rate helps in identifying changes that may indicate deterioration in the infant’s condition related to increased intracranial pressure.

A. Grilled chicken over romaine lettuce provides protein but lacks sufficient calcium and vitamin D, which are essential for bone health.

B. Salmon patties and collard greens are rich in calcium and vitamin D, which are crucial for osteoporosis prevention. Salmon contains vitamin D, and collard greens are high in calcium.

C. Tuna and sautéed spinach provide protein and some vitamins, but they may not be as rich in calcium and vitamin D compared to salmon and collard greens.

D. Beef steaks and asparagus offer protein and some nutrients but lack the high levels of calcium and vitamin D needed for bone health.