Question

A 3-year-old client with cerebral concussion is being observed overnight on a pediatric unit. Which of the following observations would be most significant for the nurse to report to the oncoming shift?

1. The client has a BP of 94/58 mm Hg and an apical pulse of 90.

2. The client is sleeping but is easily aroused

3. The client's pupils are equal and reactive to light.

4. The client has an axillary temperature of 99.0F (37.2 C) and respirations of 24.

Explain why the answer is choosen as well and why wouldnt it be the other options?

Answer 1

The correct option is 4) The client has an axillary temperature of 99.0F (37.2 C) and respirations of 24.

Because there is a slight increase in axillary temperature and it might be the beginning of the complication of cerebral concussion - infection .

The normal axillary temperature is between 96 .6°F to 98° F

The other options are under normal range.

Answer 2

3 because it's if the pupils re unequal it's a big problem.