Level: Foundational
Difficulty: Easy
Subtopic: Pediatric vital signs
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for febrile illness in a toddler. Assessment…
Pediatric nursing Clinical Judgment Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for febrile illness in a toddler. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Using the clinical judgment model, what is the nurse's first step?
Question
A. Implement the first intervention on the existing care plan without reviewing new data.
B. Evaluate discharge readiness before addressing acute findings.
C. Document the assessment at the end of the shift and continue the prior plan.
D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
B. Evaluate discharge readiness before addressing acute findings.
C. Document the assessment at the end of the shift and continue the prior plan.
D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale
Correct answer: D. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.