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.

Question

Quizplus · Accepted Answer

These symptoms indicate meningeal irritation and need immediate evaluation.Continuing the assessment is not necessary.No indication of injury is present.This is not descriptive of head lag.

The Nurse Has Just Started Assessing a Young Child Who