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 intervention best reduces the client's risk of complications?
Question
A. Restrict all movement without individualized assessment.
B. Delay teaching until the day of discharge only.
C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
B. Delay teaching until the day of discharge only.
C. Identify risk early, implement prevention measures, teach warning signs, and plan timely reassessment.
D. Ignore small changes until they become severe.
Rationale
Correct answer: C. 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.