The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. What clinical manifestation is the most essential part of the nursing assessment to detect early signs of a worsening condition?
a. Posturing
b. Vital signs
c. Focal neurologic signs
d. Level of consciousness
ANS: D
The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of an injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing is indicative of neurologic damage.
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