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?
a. Refer for immediate medical evaluation.
b. Continue assessment to determine cause of neck pain.
c. Ask parent when neck was injured.
d. Record "head lag" on assessment record, and continue assessment of child.
ANS: A
Hyperextension of the child's head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation; it is not descriptive of head lag. The pain is indicative of meningeal irritation. No indication of injury is present.
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