A 3-year-old is brought to the emergency department by ambulance after her body was found submerged in the family pool. The child has altered mental status and shallow respirations. She did not require resuscitative interventions
Which condition should the nurse monitor first in this child? a. Neurologic status
b. Hypothermia
c. Hypoglycemia
d. Hypoxia
D
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A Although a neurologic assessment will be required, it is not the area of primary
assessment. The airway is always assessed first.
B Hypothermia offers protection to the brain. It is a concern, but not the area of
primary concern.
C Although the child may have electrolyte imbalances, this is not the primary
assessment area.
D Hypoxia is responsible for the injury to organ systems during submersion
injuries. Hypoxia can progress to cardiopulmonary arrest. Monitoring the airway
is always the number one concern.
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