Difficulty: Medium
Average Score: 79%
Simulated
Passage / Scenario
10-month-old child following a head injuryA nurse is caring for a 10-month-old child who was brought to the emergency department by his parents following a head injury. Which of the following actions should the nurse take first?
Correct answer
A
Rationale
The correct answer is A: Assess respiratory status. This is the first action the nurse should take as airway and breathing are the top priorities in any emergency situation. Ensuring the child has a patent airway and is breathing adequately is crucial for their survival. Assessing respiratory status includes observing for signs of distress, such as increased respiratory rate, use of accessory muscles, and abnormal breath sounds. This initial assessment will help the nurse determine the child's immediate needs and guide further interventions.
Inspecting for fluid leaking from the ears (B) and examining the scalp for lacerations (C) are important assessments but should come after ensuring the child's respiratory status is stable. Checking pupil reactions (D) is also important but not as immediate as assessing respiratory status in this scenario.
Inspecting for fluid leaking from the ears (B) and examining the scalp for lacerations (C) are important assessments but should come after ensuring the child's respiratory status is stable. Checking pupil reactions (D) is also important but not as immediate as assessing respiratory status in this scenario.