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.The most appropriate action is to:
A) Refer for immediate medical evaluation.
B) Continue the assessment to determine the cause of neck pain.
C) Ask the parent when the child's neck was injured.
D) Record "head lag" on the assessment record and continue the assessment of the child.
Correct Answer:
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