A 5-year-old patient has been brought in for a routine check-up and vaccination update.
The mother reports that the child has been having difficulty focusing in school and has shown a decreased appetite in recent weeks.
What actions should the nurse take?

Answer and explanation

The correct answer is Choice D.

Choice A rationale

Checking the client’s temperature, blood sugar, and urine output could be important in certain situations, but in this case, it may not be the most immediate need. The client is wandering and crying, which suggests emotional distress rather than a physical health issue.

Choice B rationale

Arranging for the client to be transported for laboratory tests and an electrocardiogram (ECG) would be an overreaction in this situation. There’s no indication from the client’s behavior that they are experiencing a medical emergency.

Choice C rationale

Delegating care of the crying client to an unlicensed assistant is not the best choice. The client is likely experiencing emotional distress due to the traumatic event, and they would benefit from the care and attention of a trained professional.

Choice D rationale

Directing the client to the shelter’s nutrition center to obtain water and food is the best action in this situation. The client may be dehydrated or hungry, which could be contributing to their distress. Providing for these basic needs can help to calm the client and provide a sense of safety and stability.

Answer and explanation The correct answer is D. Choice A rationale

Giving a complete bed bath to further assess the client may not be the most appropriate intervention in this case. The client is semi-conscious and cries out in pain when turned or moved. A complete bed bath could potentially cause unnecessary discomfort and distress.

Choice B rationale

Removing the fentanyl patch as directed by prescription may not be the best course of action. Fentanyl is a powerful opioid used to manage severe pain. The client’s parents report that their child cries out in pain when turned or moved, suggesting that the client is experiencing significant pain. Removing the fentanyl patch could potentially exacerbate the client’s pain.

Choice C rationale

Calling for ambulance transportation to the hospital immediately may not be necessary at this time. The client’s vital signs are stable, and there is no indication of an immediate medical emergency based on the information provided.

Choice D rationale

Discussing end-of-life decisions with the client’s parents is the most appropriate intervention. The client is semi-conscious, sleeps most of the time, and is in significant pain. These symptoms suggest that the client’s condition is deteriorating. It is important to have conversations about end-of-life care preferences and decisions to ensure that the client’s wishes are respected and that the parents are prepared.