Level: Foundational
Difficulty: Easy
Subtopic: School-age development
NCLEX: An 8-year-old child at a school health screening is being evaluated for developmental expectations for school-age…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
An 8-year-old child at a school health screening is being evaluated for developmental expectations for school-age development. Assessment data include the child reports bullying and declining school performance. 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. Complete nonurgent tasks first because the client appears calm.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Complete nonurgent tasks first because the client appears calm.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.