Level: Advanced
Difficulty: Hard
Subtopic: Family-centered care
NCLEX: An 8-year-old child in the pediatric unit is being evaluated for family presence during hospitalization. Assessme…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An 8-year-old child in the pediatric unit is being evaluated for family presence during hospitalization. Assessment data include nasal flaring, grunting, retractions, and SpO2 89%. 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. Long-term teaching before treating acute physiologic risk.
D. Airway, breathing, and circulation problems before comfort or psychosocial needs.
B. Visitor concerns before physiologic stability.
C. Long-term teaching before treating acute physiologic risk.
D. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale
Correct answer: D. 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.