MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation
The nurse has received report on four children. Which child should the nurse
assess first?
a. A school-age child in a coma with stable vital signs
b. A preschool child with a head injury and decreasing level of consciousness
c. An adolescent admitted after a motor vehicle accident is oriented to person and
place
d. A toddler in a persistent vegetative state with a low-grade fever - Ans>>b. A
preschool child with a head injury and decreasing level of consciousness
,ANS: B
The nurse should assess the child with a head injury and decreasing level of
consciousness first (LOC).
Assessment of LOC remains the earliest indicator of improvement or deterioration
in neurologic status.
The next child the nurse should assess is a toddler in a persistent vegetative state
with a low-grade fever.
The school-age child in a coma with stable vital signs and the adolescent admitted
to the hospital who is
oriented to his surroundings would be of least worry to the nurse.
MSC: Area of Client Needs: Safe and Effective Care Environment: Management of
Care
The nurse is performing a Glasgow Coma Scale on a school-age child with a head
injury. The child opens eyes spontaneously, obeys commands, and is oriented to
person, time, and place. Which is the score the nurse should record?
a. 8
b. 11
, c. 13
d. 15 - Ans>>d. 15
ANS: D
The Glasgow Coma Scale (GCS) consists of a three-part assessment: eye opening,
verbal response, and
motor response. Numeric values of 1 through 5 are assigned to the levels of
response in each category.
The sum of these numeric values provides an objective measure of the patient's
level of consciousness
(LOC). A person with an unaltered LOC would score the highest, 15. The child who
opens eyes
spontaneously, obeys commands, and is oriented is scored at a 15.
The nurse is closely monitoring a child who is unconscious after a fall and notices
that the child suddenly has a fixed and dilated pupil. How should the nurse
interpret these findings?
a. Eye trauma
b. Neurosurgical emergency
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