Which of these clients should the nurse assess first?
A)A 10-year-old boy who is scheduled for a tonsillectomy in an hour
B)A 3-year-old boy who had an episode of tonic-clonic seizure a day ago
C)A 5-year-old child on a gluten-restricted diet initiated 48 hours ago
D)A 6-month-old child sleeping quietly with bulging and tense anterior fontanel

Question

Quizplus · Accepted Answer

A bulging and tensed anterior fontanel is indicative of increased intracranial pressure, a serious medical problem. Increased pressure can damage the brain or the spinal cord; therefore, it should be the nurse's first priority. The child on a gluten-restricted diet would have adjusted to the diet and the child with an episode of seizure would have to be closely monitored. Though it is important to give preoperative preparations to the 10-year-old for a tonsillectomy, it does not take priority over an infant with increased ICP.

Which of These Clients Should the Nurse Assess First