Level: Advanced
Difficulty: Hard
Subtopic: Pediatric pain
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for postoperative pain in a school-age child….
Pediatric nursing Clinical Judgment Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for postoperative pain in a school-age child. Assessment data include pulling at ears and crying with tugging on the right ear. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
C. Evaluate discharge readiness before addressing acute findings.
D. Document the assessment at the end of the shift and continue the prior plan.
Rationale
Correct answer: B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.