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 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.

Question

Quizplus · Accepted Answer

These symptoms indicate meningeal irritation and needs 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