Level: Advanced
Difficulty: Hard
Subtopic: Pediatric pain
NCLEX: A 6-month-old infant in the pediatric clinic is being evaluated for postoperative pain in a school-age child. Ass…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
A 6-month-old infant in the pediatric clinic is being evaluated for postoperative pain in a school-age child. Assessment data include parents report decreased wet diapers and lethargy over 24 hours. Which finding requires the nurse to intervene immediately?
Question
A. A stable, long-standing finding that matches the expected care plan.
B. The new finding that parents report decreased wet diapers and lethargy over 24 hours.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
B. The new finding that parents report decreased wet diapers and lethargy over 24 hours.
C. A comfort request with unchanged vital signs and no new symptoms.
D. Routine data unchanged from the prior assessment.
Rationale
Correct answer: B. The new finding that parents report decreased wet diapers and lethargy over 24 hours.
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.