Level: Advanced
Difficulty: Hard
Subtopic: Child safety
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for pediatric injury prevention. Assessment d…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for pediatric injury prevention. Assessment data include parents report decreased wet diapers and lethargy over 24 hours. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Pain relief before checking airway and breathing.
B. Visitor concerns before physiologic stability.
C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
B. Visitor concerns before physiologic stability.
C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.