Level: Clinical
Difficulty: Medium
Subtopic: Respiratory illness
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for bronchiolitis with respiratory distress. Asse…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for bronchiolitis with respiratory distress. Assessment data include parents report decreased wet diapers and lethargy over 24 hours. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that parents report decreased wet diapers and lethargy over 24 hours.
D. Routine data unchanged from the prior assessment.
B. A comfort request with unchanged vital signs and no new symptoms.
C. The new finding that parents report decreased wet diapers and lethargy over 24 hours.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: C. The new finding that parents report decreased wet diapers and lethargy over 24 hours.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.