Level: Foundational
Difficulty: Easy
Subtopic: Growth and development
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for well-child care. Assessment data include pulling at ears and crying with tugging on the right ear. Which documentation should the nurse record to best support safe care and communication?
Question
A. "Client fine; no changes noted."
B. Copied yesterday's note without updating current assessment data.
C. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
D. Subjective opinions only without measurable findings.
B. Copied yesterday's note without updating current assessment data.
C. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: C. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.