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 intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
C. Delay teaching until the day of discharge only.
D. Ignore small changes until they become severe.
Rationale
Correct answer: B. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Risk reduction focuses on early identification, prevention, teaching, and reassessment rather than unnecessary restriction or delay.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.