A 6-year-old with a severe closed-head injury is unconscious. His heart rate has dropped from 120 to 55, blood pressure increased from 110/44 to 195/62, and respirations are becoming more irregular. After calling the physician, which action should the nurse take first?

Correct Answer: A

Rationale: Prepare mannitol with help is first for Cushing triad (bradycardia, hypertension, irregular breathing) in head injury, per neurocritical care, indicating severe ICP needing osmotic reduction. Fluids worsen ICP; antihypertensive mistreats; oxygen insufficient. As urgency makes itthe correct answer.

Correct Answer: B

Rationale: Feel at ease with parents present is best, per family-centered care. Parental presence comforts, aiding assessment. Cooperation , policy , and fear lack support. Bs empathy makes itthe correct answer.

Correct Answer: B

Rationale: 17-day-old with GBS meningitis is at high CP risk, per neurology texts. CNS infection damagmotor areas. Preterm is moderate risk; febrile seizure and head injury less direct. Bs etiology makes itthe correct answer.

Correct Answer: B

Rationale: Loosen clothing and call for help is best during a seizure, per epilepsy guidelines. It ensursafety and support without leaving the child. Oral meds and tongue bladare unsafe; carrying risks injury. Bs practicality makes itthe correct answer.

Correct Answer: A

Rationale: Red blood cell transfusion is included for neuroblastoma with pancytopenia, per oncology texts, addressing anemia from marrow involvement. School , Coumadin , and diet dont fit. As necessity makes it the correct answer.