What should be the nurse's first action when a child with a head injury complains of double vision and a headache and then vomits?
a. Immobilize the child's neck.
b. Report this information to the physician.
c. Darken the room and put a cool cloth on the child's forehead.
d. Restrict the child's oral fluid intake.
B
Any indication of increased intracranial pressure should be promptly reported to the physician. Stabilizing the child's neck does not address the child's symptoms. Darkening the room and putting a cool cloth on the child's forehead may facilitate the child's comfort. It would not be the nurse's first action. The child's episode of vomiting does not necessitate a fluid restriction.
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