A pediatric nurse is caring for a 7-year-old client admitted with a severe asthma exacerbation. The client's parents, who are undergoing a contentious divorce, begin arguing loudly at the bedside about custody arrangements. The client starts crying, and the nurse observes increased work of breathing and audible wheezing. Which nursing action is the priority?
- AInform the parents that their arguing is selfish and they need to focus entirely on their child's recovery.
- BProvide the parents with educational materials about emotional stress as an asthma trigger to read at the bedside.
- Direct the parents to step outside the room immediately while staying to assess and support the client's respiratory status.Cevap
- DEncourage the 7-year-old client to verbalize to the parents how their fighting is causing the breathing problems.
Cevap
The priority is to direct the parents to step outside the room to remove the environmental trigger, while the nurse remains to assess the client's breathing.
The client is exhibiting acute signs of respiratory distress (wheezing, increased work of breathing) secondary to emotional distress. According to Maslow's hierarchy of needs and the ABCs (Airway, Breathing, Circulation) of nursing prioritization, the immediate physiological threat must be addressed first. By directing the parents out of the room, the nurse removes the acute psychosocial trigger while remaining present to assess and manage the client's compromised airway and breathing.
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Anahtar Kavram
Managing maladaptive family dynamics and prioritizing physiological safety