The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. Which is the most appropriate action?
a. Ask the parent when the neck was injured.
b. Refer for immediate medical evaluation.
c. Continue assessment to determine the cause of the neck pain.
d. Record "head lag" on the assessment record and continue the assessment of the child.
ANS: B
Hyperextension of the child's head with pain on flexion is indicative of meningeal irritation and needs immediate evaluation. No indication of injury is present. This situation is not descriptive of head lag.
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