Exam (elaborations) CRITICAL THINKING

1. The nurse is working in the emergency department (ED) of a children's medical center. Which client should the nurse assess first? 1. The 1-month-old infant who has developed colic and is crying. 2. The 2-year-old toddler who was bitten by another child at the day-care center. 3. The 6-year-old school-age child who was hit by a car while riding a bicycle. 4. The 14-year-old adolescent whose mother suspects her child is sexually active. Rationale Correct - 3-The child hit by a car should be assessed first because he or she may have life- threatening injuries that must be assessed and treated promptly. 2. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first? 1. Administer 6 L of oxygen via nasal cannula. 2. Assess the client's neurological status. 3. Administer a narcotic analgesic by intravenous push (IVP). 4. Increase the client's intravenous (IV) rate. Rationale Correct - 2-Because the client is complaining of a headache, the nurse should first rule out cerebrovascular accident (CVA) by assess- ing the client's neurological status and then determine whether it is a headache that can be treated with medication.