Level: Foundational
Difficulty: Easy
Subtopic: Toddler and preschool development
NCLEX: A 3-year-old child in the pediatric clinic is being evaluated for developmental expectations for toddler and pres…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 3-year-old child in the pediatric clinic is being evaluated for developmental expectations for toddler and preschool development. Assessment data include the caregiver reports new bed-wetting after a family stressor. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
D. Wait for the provider's routine visit before acting on abnormal findings.
Rationale
Correct answer: C. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.