Four children are brought to the emergency department. Which child should be assessed first?

Question

Quizplus · Accepted Answer

Clear, colorless fluid draining from the nose or ears after head trauma is suspicious for cerebrospinal fluid (CSF) leakage (Option C). When the drainage is clear, dextrose testing can be used to determine if the drainage is CSF. However, the presence of blood would make this test unreliable as blood also contains glucose. This child is at risk for intracerebral bleeding and meningitis. Vascular compromise may occur with even minimal head trauma; therefore, the nurse should evaluate any changes in level of consciousness and temperature as well as assess the head and neck for subcutaneous bleeding. The nurse should anticipate a CT scan of the head and neck and prophylactic antibiotics. (Option A) Iron ingestion is the major concern with vitamin toxicity in children. However, children's formulations contain minimal or no iron. As a result, ingestion of an unknown quantity is unlikely to cause serious toxicity. This child should be seen second. (Option B) A low-grade fever is common after immunizations; this child can be seen last. (Option D) Although infection and pain are important, this child can be seen third. Educational objective: The child with head trauma who is leaking cerebrospinal fluid (CSF) is at risk for meningitis and intracerebral bleeding. If the drainage is clear, a dextrose test is used to determine if the drainage is CSF. The nurse should assess for signs of bleeding (eg, change in level of consciousness) and infection (eg, increased temperature) and anticipate a CT scan and prophylactic antibiotics.

Four Children Are Brought to the Emergency Department