Pediatric nursing · practice question

A 2-year-old toddler in the emergency department is being evaluated for family presence during hospitalization. Assessment data include pulling at ears and crying with tugging on the right ear. Which nursing action should the nurse take first?

Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026pediatric-nursing

Give a blanket answer that everything is fine and continue the prior plan.Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Answer and explanation

Correct answer

D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

Test yourself on Pediatric nursing

A free test with instant, explained results. No account needed.

Start free test

All Pediatric nursing questions →

A 2-year-old toddler in the emergency department is being evaluated for family presence during hospitalization. Assessment data include pulling at ears and crying with tugging on the right ear. Which nursing action should the nurse take first?

Correct answer

Why

More Pediatric nursing questions