Level: Advanced
Difficulty: Hard
Subtopic: Pediatric pain
NCLEX: An 8-year-old child in the pediatric unit is being evaluated for postoperative pain in a school-age child. Assess…
Pediatric nursing Health Promotion and Maintenance Physiological Adaptation
Case Study
An 8-year-old child in the pediatric unit is being evaluated for postoperative pain in a school-age child. Assessment data include capillary refill 4 seconds with dry mucous membranes and sunken fontanelle. Which documentation should the nurse record to best support safe care and communication?
Question
A. "Client fine; no changes noted."
B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: B. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Safe documentation is specific, objective, and reflects assessment, intervention, response, and escalation when needed.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.