Difficulty: Medium
Average Score: 79%
Simulated
Passage / Scenario
The following scenario applies to the next 1 itemsThe emergency department (ED) nurse is caring for a 15-year-old who has sustained a sports-related injury
Item 1 of 1
Triage Note Triage Vital Signs
1330: A 15-year-old female was participating in cheerleading practice and fell to the ground while in the air. Witnesses said that she hit her head and 'blacked out,' and the client reports no recall of the event. The client endorses left occipital head pain with tenderness to the affected area. Slight swelling noted. The client reports headache as a '7' (0 = no pain, 10 = worst pain). She is lethargic and oriented.
The nurse assigned to the client reviews the triage note and plans care
The nurse anticipates taking which action? Prepare the client for a computed tomography (CT) scan of the head
Correct answer
A,A,B,A,B
Rationale
A CT scan is indicated to assess for brain injury in a client with head trauma and loss of consciousness. GCS assessment is critical to evaluate neurological status post-head injury. Encouraging PO fluids is inappropriate until a CT scan rules out increased intracranial pressure. Pupil assessment is essential to detect neurological changes post-head trauma. Lumbar puncture is not indicated unless specific conditions like meningitis are suspected.