The Nurse Has Just Started Assessing a Young Child Who

question 21

Multiple Choice

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.

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Definitions:

Striated Involuntary

Relating to muscle tissue that is marked by a pattern of stripes or striations and is not under conscious control, such as the heart muscle.

Axons

Long, slender projections of nerve cells (neurons) that transmit electrical impulses away from the neuron's cell body.

Action Potentials

Rapid changes in the electrical charge of a neuron's membrane, facilitating the transmission of nerve impulses.

Neurons

Specialized cells within the nervous system that transmit information to other neurons, muscles, or gland cells.