Level: Foundational
Difficulty: Easy
Subtopic: Growth and development
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
B. Assume understanding without checking literacy or readiness.
C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: C. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.