The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which of the following is the most appropriate action?
A) Refer for immediate medical evaluation.
B) Continue assessment to determine cause of neck pain.
C) Ask parent when neck was injured.
D) Record "head lag" on assessment record, and continue assessment of child.
Correct Answer:
Verified
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