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 temperature 103.1°F (39.5°C) with a new petechial rash. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: B. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.