Level: Clinical
Difficulty: Medium
Subtopic: Congenital disorders
NCLEX: An 8-year-old child in the pediatric unit is being evaluated for newly diagnosed congenital heart disease. Assess…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An 8-year-old child in the pediatric unit is being evaluated for newly diagnosed congenital heart disease. Assessment data include temperature 103.1°F (39.5°C) with a new petechial rash. Which finding requires the nurse to intervene immediately?
Question
A. The new finding that temperature 103.1°F (39.5°C) with a new petechial rash.
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 temperature 103.1°F (39.5°C) with a new petechial rash.
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.