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The Nurse Has Just Started Assessing a Young Child Who

Question 22

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The nurse has just started assessing a young child who is febrile and appears ill.There is hyperextension of the child's head (opisthotonos) with pain on flexion.Which is the most appropriate action?


A) Ask the parent when the neck was injured.
B) Refer for immediate medical evaluation.
C) Continue assessment to determine the cause of the neck pain.
D) Record "head lag" on the assessment record and continue the assessment of the child.

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