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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Respiratory rate can be influenced by many factors, including fever or anxiety, and is not the most reliable indicator of fluid loss.

B. Blood pressure may change with severe dehydration, but it can be a late sign, and other factors (like shock) can also affect blood pressure, so it's not the most reliable early indicator.

C. Body weight is the most reliable and sensitive indicator of fluid loss, as even small changes in weight reflect changes in hydration status. Monitoring weight helps assess fluid loss accurately.

D. Skin integrity can be affected by dehydration, but it's not the most reliable indicator of fluid loss. It may take longer to show visible signs such as dry skin or poor turgor.

A. Tonic-clonic seizure B. Myoclonic seizure C. Atonic seizure D. Absence seizure

Correct Answer is C

Explanation

A. Tonic-clonic seizure. Tonic-clonic seizures involve both muscle stiffness (tonic phase) and jerking movements (clonic phase), but they are not characterized by a sudden loss of muscle tone.

B. Myoclonic seizure. Myoclonic seizures involve brief, sudden jerks or twitches of a muscle or group of muscles, not the sudden loss of muscle tone.

C. Atonic seizure. Atonic seizures, also known as "drop attacks," are characterized by a sudden loss of muscle tone, which causes the person to collapse or fall to the ground. This is the correct description of the type of seizure being asked about.

D. Absence seizure. Absence seizures involve brief episodes of staring and loss of awareness but do not cause loss of muscle tone or collapsing.

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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?

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