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. The nurse reviews this trend: withdrawal score increased with tremor, diaphoresis, and rising blood pressure. Which interpretation and action are most appropriate?
Question
A. Ignore the trend because one data point can be explained later.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
B. Treat a single value without comparing it with baseline, symptoms, or benchmarks.
C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
D. Wait for a critical value or sentinel event before taking any nursing action.
Rationale
Correct answer: C. Interpret the trend in context, compare it with baseline or benchmarks, and take the safest indicated action.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Trend questions require comparison with baseline, symptoms, risk, and benchmarks. Safe nursing action begins before a preventable event becomes critical.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.