Level: Foundational
Difficulty: Easy
Subtopic: Toddler and preschool development
NCLEX: A 3-year-old child in the pediatric clinic is being evaluated for developmental expectations for toddler and pres…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 3-year-old child in the pediatric clinic is being evaluated for developmental expectations for toddler and preschool development. Assessment data include the child has frequent tantrums and the caregiver asks about limit setting. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.