Health Promotion and Maintenance
83. A nurse and nursing student are caring for a child who sustained a head injury as a result of a fall from a play structure. The nurse knows the nursing student is prepared to care for the child when the student states:
. "I will be sure to let you know if the child's pupils become fixed and dilated."
. "I will keep the child straight in the supine position."
. "I will look for any changes in the child's respirations, pulse, or blood pressure."
. "I will notify the physician if the child becomes sleepy."
Test-Taking Tip
Think: vital signs! Nurses should monitor clients with head injury for changes in vital signs because these may indicate problems with neurological functioning.
Content Area: Child Health, Neurological; Integrated Process: Nursing Process, Evaluation; Cognitive Level: Analysis; Client Need/Subneed: Physiological Integrity/Reduction of Risk Potential/System Specific Assessments
Health Promotion and Maintenance
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Answer 1 is incorrect since the student should recognize and alert the nurse to more subtle ocular changes, such as sluggishness or unequal reactions, prior to the time that the pupils become fixed and dilated and the child is in a potentially irreversible state. Answer 2 is incorrect because the child should be straight, but with the head of bed slightly elevated. Answer 3 is correct because this statement is evidence that the student understands that alterations in any of these vital signs could be an indication of worsening condition and should be promptly noted. Answer 4 is incorrect because sleeping is a normal behavior for children, especially if they have been examined frequently throughout the day. The student should assess the child frequently, waking the child as necessary without assuming that a sleeping child warrants a call to the practitioner.