Level: Foundational
Difficulty: Easy
Subtopic: Immunizations
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for routine childhood immunizations. Assessme…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for routine childhood immunizations. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that capillary refill 4 seconds with dry mucous membranes and sunken fontanelle.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. A stable, long-standing finding that matches the expected care plan.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: A. The new finding that capillary refill 4 seconds with dry mucous membranes and sunken fontanelle.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.