The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of nursing assessment to detect early signs of a worsening condition is
a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness
D
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A Neurologic posturing is indicative of neurologic damage.
B Vital signs and focal neurologic signs are later signs of progression when
compared with level-of-consciousness changes.
C Vital signs and focal neurologic signs are later signs of progression when
compared with level-of-consciousness changes.
D The most important nursing observation is assessment of the child's level of
consciousness. Alterations in consciousness appear earlier in the progression of
head injury than do alterations of vital signs or focal neurologic signs.
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