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 documentation should the nurse record to best support safe care and communication?
Question
A. Objective assessment findings, nursing actions taken, client response, and provider notification when indicated.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
B. "Client fine; no changes noted."
C. Copied yesterday's note without updating current assessment data.
D. Subjective opinions only without measurable findings.
Rationale
Correct answer: A. 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.