A nurse is caring for a 13-year-old adolescent in the pediatric emergency room who has a suspected head injury. Which of the following actions should the nurse take first?
Notify the adolescent's primary care provider.
Collect a detailed past medical history.
Perform a thorough assessment noting acute conditions
Administer pain medication to the adolescent.
The Correct Answer is C
A. Notify the adolescent's primary care provider is incorrect. While it is important to notify the healthcare provider, the immediate priority is performing a thorough assessment to determine the severity of the head injury and any potential complications, such as changes in consciousness or neurological status.
B. Collect a detailed past medical history is incorrect. Although collecting medical history is important, it is not the priority in the acute phase of a suspected head injury. The priority is to assess the current condition of the adolescent, especially signs of deterioration.
C. Perform a thorough assessment noting acute conditions is correct. The priority in suspected head injuries is to perform a thorough assessment to evaluate the patient's neurological status. This includes checking for signs of a concussion, increased intracranial pressure, or any other acute conditions that may require immediate intervention.
D. Administer pain medication to the adolescent is incorrect. Pain management is important, but it should not be the first action when a head injury is suspected, as it can mask symptoms or affect the ability to assess neurological function properly.
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Related Questions
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.
Correct Answer is D
Explanation
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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