A nurse is assessing a child who has a suspected head injury. What would be the initial action the nurse should take to assess the child's cognitive status?

Have blood work done

Monitor intracranial pressure

Recommend a CT scan

Use the Glasgow cognitive scale

Answer and Explanation

The Correct Answer is D

A. Have blood work done is not the initial priority for assessing cognitive status in a child with a suspected head injury. Blood work may be ordered later to assess for any contributing factors but is not the first step in cognitive assessment.

B. Monitor intracranial pressure is important but typically comes after an initial cognitive assessment. Elevated intracranial pressure may be suspected after assessing cognitive function and other neurological signs.

C. Recommend a CT scan might be ordered by a healthcare provider to assess for structural brain damage, but the initial assessment of cognitive status should be done first to evaluate the severity of the injury.

D. Use the Glasgow cognitive scale is the correct initial action. The Glasgow Coma Scale (GCS) is used to assess a child's level of consciousness and cognitive function following a head injury. It helps determine the severity of the injury and guides further intervention.

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Correct Answer is B

Explanation

A. Glasgow Coma Scale (GCS) assessment is used to assess the level of consciousness in patients with head trauma or neurological conditions, but it is not the diagnostic test for suspected meningitis.

B. Cerebrospinal fluid (CSF) analysis is the definitive test for diagnosing meningitis. A lumbar puncture is performed to obtain a sample of CSF, which is then analyzed for signs of infection, such as increased white blood cells, proteins, and low glucose levels.

C. RBC count is useful for assessing anemia and other hematological conditions, but it is not specific to diagnosing meningitis.

D. Magnetic resonance imaging (MRI) can be used to assess brain structure, but CSF analysis remains the primary diagnostic tool for confirming meningitis based on the clinical signs of fever, headache, stiff neck, and rash.

A. Obtain IV access. B. Keep a padded tongue blade available at the client's bedside. C. Keep the lights on when the client is sleeping. D. Place the client's bed in the high position.

Correct Answer is A

Explanation

A. Obtain IV access. Obtaining IV access is a good precaution in case the client requires emergency medication (e.g., anticonvulsants) to control seizures. This is part of preparing for seizure management.

B. Keep a padded tongue blade available at the client's bedside. This is an outdated practice. The nurse should never insert a tongue blade into a patient's mouth during a seizure as it can cause injury.

C. Keep the lights on when the client is sleeping. There is no need to keep the lights on, as it may disturb the client’s rest. A calm, quiet environment is preferred, and seizure precautions are more related to safety and monitoring than lighting.

D. Place the client's bed in the high position. This increases the risk of injury in the event of a seizure. The bed should be in a low position with side rails up to prevent injury.

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A nurse is assessing a child who has a suspected head injury. What would be the initial action the nurse should take to assess the child's cognitive status?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

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