Level: Foundational
Difficulty: Easy
Subtopic: School-age development
NCLEX: An 8-year-old child at a school health screening is being evaluated for developmental expectations for school-age…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
An 8-year-old child at a school health screening is being evaluated for developmental expectations for school-age development. Assessment data include the child has new headaches before school and asks to stay home. 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. Administer the next scheduled intervention before reassessing the client.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Administer the next scheduled intervention before reassessing the client.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale
Correct answer: D. 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.