Level: Clinical
Difficulty: Medium
Subtopic: Dehydration
NCLEX: A 2-year-old toddler in the emergency department is being evaluated for dehydration from vomiting and diarrhea. A…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 2-year-old toddler in the emergency department is being evaluated for dehydration from vomiting and diarrhea. Assessment data include pulling at ears and crying with tugging on the right ear. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that pulling at ears and crying with tugging on the right ear.
B. A comfort request with unchanged vital signs and no new symptoms.
C. Routine data unchanged from the prior assessment.
D. The new finding that pulling at ears and crying with tugging on the right ear.
Rationale
Correct answer: D. The new finding that pulling at ears and crying with tugging on the right ear.
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.