A nurse is collecting data from a toddler who weighs 20 kg (44 lb) and has a full thickness burn to 10% of this body.
Which of the following findings should the nurse report 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.

Choice A rationale

Brisk capillary refill is a normal finding and does not require intervention.

Choice B rationale

Tachypnea, or rapid breathing, is a common symptom of respiratory syncytial virus (RSV) infection in infants. It can indicate that the infant is having difficulty breathing and needs immediate intervention.

Choice C rationale

Rhinorrhea, or a runny nose, is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.

Choice D rationale

Coughing is a common symptom of RSV infection in infants. While it can be uncomfortable for the infant, it does not typically require immediate intervention.