ATI PN Paediatrics Nursing 2023 Proctored Exam
A nurse at an urgent care clinic is caring for a child who hit her head on the playground at school 30 min ago. Which of the following findings is the nurse's priority?
Explanation & Rationale
A. Nasal discharge negative for glucose indicates that there is no cerebrospinal fluid (CSF) leakage, which is a positive sign. While it is important to note, it is not the priority in this situation. B. A negative Babinski reflex is a normal finding in children older than 2 years. It does not indicate an acute issue and is not the priority. C. Asymmetric pupils can be a sign of increased intracranial pressure or a serious brain injury, making this the priority finding. It requires immediate attention to prevent further complications. D. A 2 cm scalp laceration, while needing medical attention, is not life-threatening and is not the highest priority compared to potential brain injury indicated by asymmetric pupils.
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