NCLEX RN Exam Practice Practice Question
Which action by the nursing student, caring for a child who sustained a head injury from a fall, indicates a need for further teaching?
Correct Answer: A
Rationale: A child with a head injury is at risk for increased intracranial pressure (ICP). Forcing fluids may cause fluid overload and increased ICP. Additionally, the nurse should not 'force' the client to do something. Neurological assessments must be performed to monitor for increased ICP. Sitting up will decrease fluid retention in cerebral tissue and promote drainage. Keeping the child awake will assist in accurate evaluation of any cerebral edema that is present and will detect early coma.
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