Question

The nurse has just started assessing a young child who is febrile and appears ill. There is hyperextension of the childs head (opisthotonos) with pain on flexion. Which is the most appropriate action?

A) Administering pain medication
B) Initiating immediate antibiotic therapy
C) Performing a lumbar puncture to assess cerebrospinal fluid
D) Encouraging the child to move the head to relieve discomfort

Answer 1

Perform a lumbar puncture to assess cerebrospinal fluid and initiate antibiotic therapy if meningitis is diagnosed.

Step-by-step explanation:

The most appropriate action for a nurse assessing a young child who is febrile and appears ill, with hyperextension of the child's head (opisthotonos) and pain on flexion, would be to perform a lumbar puncture to assess cerebrospinal fluid (CSF).

Meningitis, an infection of the tissue surrounding the brain and spinal cord, can present with these symptoms. A lumbar puncture is the primary test for meningitis, where a needle is inserted into the spinal canal to collect a sample of CSF for analysis. If meningitis is diagnosed, antibiotic therapy would be initiated to treat the infection.