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

Correct Answer: A

Rationale: Referring the child for immediate medical evaluation is the most appropriate action in this scenario. The symptoms described, including hyperextension of the head (opisthotonos) with pain on flexion, are concerning for meningitis, a serious infection that can rapidly progress and lead to serious complications if not treated promptly. Seeking immediate medical intervention is crucial to assess and manage the child's condition effectively. Continuing with the assessment or asking about a neck injury is not recommended as the priority is to address the potential medical emergency. Recording the "head lag" without taking immediate action could delay necessary medical treatment.

Correct Answer: A

Rationale: At 2 months old, infants start to demonstrate more control over their arm movements and are becoming more aware of objects around them. They may also start to grasp objects intentionally. Giving a first rattle at this age can help stimulate their senses, promote sensory exploration, and encourage their fine motor skills development. This early exposure to different textures, shapes, and sounds can also aid in their cognitive and sensory development, making it an appropriate choice for a parent looking to support their baby's early growth and learning.

Correct Answer: B

Rationale: The developmental level of the child most impacts the type of injury they are susceptible to based on their age. As children grow and develop, their physical abilities, cognitive skills, and understanding of the environment change. Younger children may be more susceptible to injuries related to exploration and lack of awareness of dangerous situations, while older children may be more prone to injuries during physical activities or sports. Understanding the developmental stage of a child is crucial in assessing potential risks and implementing appropriate safety measures to prevent injuries.

Correct Answer: A

Rationale: Separation anxiety is the major stressor of hospitalization for these young patients. Toddlers and preschoolers are at a critical stage of development where they are developing close attachments to their primary caregivers. Being separated from their parents or primary caregivers when admitted to the hospital can lead to feelings of fear, distress, and insecurity. This separation can significantly impact their emotional well-being and overall hospital experience. Loss of control, fear of bodily injury, and fear of pain are also stressors associated with hospitalization, but separation anxiety is the primary concern for these young patients due to their developmental stage.

Correct Answer: A

Rationale: Giving the child as many choices as possible is an effective strategy to reduce the stress of burn dressing procedures. Allowing the child to have some control over the situation can help them feel more empowered and less anxious. By giving choices, such as letting the child choose the order in which things are done or the type of dressing used, the child is more likely to feel a sense of autonomy and reduced stress during the procedure. This approach can help the child cope better with the dressing changes and make the experience more manageable for them.