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    ATI PN Nursing Care of Children with NGN 2020 Proctored Exam

    A nurse at an urgent care clinic is caring for a child who hit her head on the playground at school 30 minutes ago. Which of the following findings is the nurse's priority?

    Explanation & Rationale

    Choice A rationale: A 2 cm scalp laceration, while a concern, is not the nurse's priority in this scenario. The child's head injury could potentially be serious, but priority should be given to neurological assessments and signs of increased intracranial pressure. Choice B rationale: Nasal discharge negative for glucose is not indicative of a major issue in this context. While cerebrospinal fluid (CSF) leaking from the nose after head trauma is a concern, it is not mentioned in this scenario, and this choice does not take precedence over other neurological signs. Choice C rationale: This is the correct answer. Asymmetric pupils can be a sign of a serious neurological issue, such as a brain injury or increased intracranial pressure. It requires immediate attention and further evaluation to assess the child's neurological status and determine the extent of the injury. Choice D rationale: A negative Babinski reflex is a normal finding in this context and does not require immediate priority attention. The Babinski reflex is typically present in infants and disappears as the child grows older. Its absence is expected in older children and adults.

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