Level: Clinical
Difficulty: Medium
Subtopic: Congenital disorders
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for newly diagnosed congenital heart disease….
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for newly diagnosed congenital heart disease. Assessment data include parents report decreased wet diapers and lethargy over 24 hours. Which documentation should the nurse record to best support safe care and communication?
Question
A. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: A. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.