Author Question: The priority nursing intervention when a child is unconscious after a fall is to: a. Establish an ... (Read 117 times)

nenivikky · **on:** Jun 28, 2018

The priority nursing intervention when a child is unconscious after a fall is to:

a. Establish an adequate airway.
b. Perform neurologic assessment.
c. Monitor intercranial pressure.
d. Determine whether a neck injury is present.

Question 2

Which test is never performed on a child who is awake?

a. Oculovestibular response
b. Doll's head maneuver
c. Funduscopic examination for papilledema
d. Assessment of pyramidal tract lesions

carolinefletcherr · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
Respiratory effectiveness is the primary concern in the care of the unconscious child. Establishing an adequate airway is always the first priority. A neurologic assessment and determination of neck injury are performed after breathing and circulation are stabilized. Intracranial, not intercranial, pressure is monitored if indicated after airway, breathing, and circulation are maintained.

Answer to Question 2

ANS: A
The oculovestibular response (caloric test) involves the instillation of ice water into the ear of a comatose child. The caloric test is painful and is never performed on a child who is awake or one who has a ruptured tympanic membrane. Doll's head maneuver, funduscopic examination, and assessment of pyramidal tract lesions can be performed on children who are awake.