A nurse is caring for a preschooler who has brain tumor.
Which of the following findings is the priority for the nurse to the provider?

Choice A rationale

Administering an antidepressant to the client is an important part of treatment for major depressive disorder. However, it is not the first action the nurse should take.

Choice B rationale

Encouraging the client to attend a group therapy session can be beneficial for the client’s recovery, but it is not the first action the nurse should take.

Choice C rationale

Assisting the client in completing his ADLs can help the client maintain a sense of normalcy and control, but it is not the first action the nurse should take.

Choice D rationale

Asking the client if he is considering harming himself is the first action the nurse should take. This is because safety is the top priority, and the nurse needs to assess the client’s risk for suicide.

The correct answer is Choice A.

Choice A rationale: Assisting with intubation is the priority action. A submersion injury can cause respiratory distress or failure, and ensuring a clear airway is critical. Intubation is often necessary to maintain oxygenation and prevent complications like hypoxia or aspiration.

Choice B rationale: Obtaining an ABG sample is important to assess the child’s oxygenation and acid-base balance, but it is not the priority action. Ensuring the airway is clear and secured takes precedence over diagnostic tests.

Choice C rationale: Administering an IV bolus might be necessary for fluid resuscitation if the child is experiencing shock, but establishing and maintaining the airway is the first critical step in managing submersion injuries.

Choice D rationale: Applying warming blankets can be important to prevent hypothermia, especially if the child has been in cold water. However, addressing airway and breathing issues is the top priority before initiating warming measures.