NCLEX-RN · Question #684
A 14-year-old boy fell off his bike while "popping a wheelie" on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of…
The correct answer is D. Offer diversionary activities. (A) CNS depressants are not given for headache due to head injury because they would mask changes in neurological status and because they could further depress the CNS. (B) The client should not be asked to think about his headache every 15 minutes. (C) Fluid intake should be…
Question
A 14-year-old boy fell off his bike while "popping a wheelie" on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:
Options
- AAsk the physician to order a sedative
- BHave the client describe his headache every 15 minutes
- CIncrease his fluid intake to 3000 mL/24 hr
- DOffer diversionary activities
How the community answered
(27 responses)- A11% (3)
- B7% (2)
- C4% (1)
- D78% (21)
Explanation
(A) CNS depressants are not given for headache due to head injury because they would mask changes in neurological status and because they could further depress the CNS. (B) The client should not be asked to think about his headache every 15 minutes. (C) Fluid intake should be normal or restricted for a client with a head injury. Normal fluid intake for a 14 year old is about 2000-2400 mL daily. (D) Diversion may help the child to focus on a pleasant activity instead of on his headache.
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