Level: Advanced
Difficulty: Hard
Subtopic: Pediatric pain
NCLEX: An 8-year-old child in the pediatric unit is being evaluated for postoperative pain in a school-age child. Assess…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An 8-year-old child in the pediatric unit is being evaluated for postoperative pain in a school-age child. Assessment data include temperature 103.1°F (39.5°C) with a new petechial rash. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: B. 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.