LPN exam pass point

A client diagnosed with panic disorder and agoraphobia is talking with the nurse about the progress made in treatment. Which statement indicates a positive client response?

"I went to the mall with my friend last Saturday."

While preparing a client for a diagnostic study of the colon, the teaches him how to self-administer a prepackaged enema. Which statement by the client indicates effective teaching?

"I will administer the enema while lying on my left side with my right knee flexed"

A 2-year-old child is being discharged from the hospital after treatment for croup. The parent asks, "What should we do if the child gets croup again?" What is the BEST response by the nurse who is reinforcing the discharge instructions?

"If the child gets another cold, watch for croup. Keep a cool-moist humidifier running in the room, and give the child lots of clear liquids."

The nurse is caring for a client diagnosed with a psychotic disorder. The nurse will monitor the client to limit water consumption to how many liters daily?

3

After a tonsillectomy, a client is being prepared for discharge. The nurse instruct the client to report which sign or symptom?

Bleeding

The nurse is obtaining data from a client with obsessive-compulsive disorder who reports not getting much sleep at night. What behavior does the nurse anticipate?

Checking the door locks multiple times

While hospitalized, a child develops C-diff infection. The nurse can anticipate adding which type of precautions for this client?

Contact precautions

A recent immigrant is diagnosed with Paul ray tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Developing a list of people with whom the client has had contact

A client is scheduled for a bronchoscopy. Pre -procedure, the nurse should instruct the client to avoid which activity?

Eating

A client with functional neurogenic symptom disorder reports blindness, and ophthalmologic examinations reveal that no physiologic disorder is causing progressive vision loss. The most likely source of this client's reported blindness is:

Having been forced to watch a loved one's torture

The nurse cares for an olde4r adolescent client. The nurse observes a visitor wearing a gun and gun holster. Which action does the nurse take?

Notify security personnel of the observation location.

A nurse prepares to put a rigid, comatose client back into bed. The client is currently propped up in a reclining chair that does not have removable arms. Which method should the nurse select as the BEST way to return this client to bed?

Obtain assistance to use a mechanical lift to move the client

An adolescent is admitted to the adolescent unit with pain caused by sickle cell crisis. Who would be consulted FIRST about this adolescent's care?

Pediatric pain specialist

The nurse observes a client, who has left-sided paralysis from a stroke, dress independently. Which action by the client indicated proper technique for dressing the upper-extremities?

Places the affected arm in the shirt before the unaffected arm

An adolescent who is newly diagnosed with type 1 diabetes provides a return demonstration of self-insulin administration. Which action by the client demonstrates proper disposal of the insulin syringe?

Placing the syringe with the uncapped needle in designated puncture-resistant container

The nurse is on the telephone with the health care provider to share the stat potassium result on a client. The health care provider gives the nurse a telephone order for potassium chloride 60 mEq oral every 6 hours for 2 days. What should the nurse do FIRST?

Repeat the potassium chloride order back to the health care provider

A nurse in a long-term care facility is delegating a task to the unlicensed assistive personnel (UAP). Which task is appropriate to assign to the UAP?

Repositioning a client every 2 hours

The nurse is caring for a group of clients with various medical diagnoses. Which client diagnosis is reportable to the public health department?

Small pox

Which nursing intervention would be most helpful for a client experiencing a panic attack?

Staying with the client and remaining calm, confident, and reassuring

A client has an in dwelling urinary catheter and is prescribed physical therapy. As the client is being placed in a wheelchair, which action by the assistant would need further clarification?

The catheter bag is placed on the client's lap for safe transport

A nurse is preparing a presentation to a group of female adolescents about pelvic inflammatory disease (PID). Which statement BEST reflects the focus of preventive education needs for this age group?

There are long-term complications related to reproductive tract infections.

The nurse is caring for a client with a panic disorder. Which panic attack the nurse document as uncued?

Upon awaking from a peaceful nap, the client reports shortness of breath

What is the nurses's initial action when preparing to insert a nasogastric (NG) tube?

Wash hands

Which nursing intervention is appropriate for a client with an arm restraint?

monitoring circulatory status every 2 hours

A client with suspected pulmonary disorder undergoes pulmonary function tests. To interpret tests results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. When reviewing the client's chart, which term will the nurse find that refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume (refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml)

An overweight girl, age 15, has lost 12 lb (5.4 kg) in 8 weeks by dieting. Now, after reaching a weight plateau, she has become discouraged. She and the nurse decide she should keep a food diary. What is the primary purpose of keeping such a diary?

To help the nurse and the client analyze the amount of food the client is eating and determine when food intake occurs

The nurse has been accused of assault and battery by a client. Which action did the nurse perform that caused the client to make this allegation?

the nurse performed a procedure without obtaining consent from the client

A nurse finds a client at high risk for falls laying on the floor unresponsive with a large hematoma noted on the client's head. After caring for the client, it is determined the client sustained a subdural hematoma and remains unresponsive. The nurse determines that the primary nurse forgot to put the client's bed in the lowest position and place the call light within reach. The primary nurse asks, "what happens next? Will I be fired?" What is the best statement by the nurse?

"Because this client sustained severe harm not expected in their course of illness, I must follow our facility's policy and complete a sentinel event form."

A client as admitted to an inpatient psychiatric unit for treatment of obsessive-compulsive disorder (OCD) symptoms. When the client's partner asks what OCD is, what is the appropriate nursing response?

"Clients with OCD experience repetitive thoughts and recurring, irresistible impulses."

A 15-year-old adolescent confides in the nurse that the adolescent has been contemplating suicide. The adolescent has developed a specific plan to Carr it out and pleads with the nurse not to tell anyone. What is the nurse's best response?

"For your protection, I can't keep this secret. After I notify the physician, we will need to involve your family. We want you to be safe."

A 15-year-old client comes to the clinic requesting a test for human immunodeficiency virus (HIV) exposure. The adolescent is concerned that her parents might be notified for her test results. Which response by the nurse is best?

"HIV testing is confidential; after we get the test results we'll discuss your options."

A nurse is caring for a 16-year-old female who is sexually active. The nurse is reinforcing education with the client about preventing sexually transmitted infections (STIs). What statement by the adolescent indicates a need for further instruction?

"I am protected from contracting HIV and other STDs because I am oral contraceptives."

During chemotherapy for lymphoma, a child, age 15, is at risk for stomatitis. Which statement by the child supports a nursing diagnosis of Deficient Knowledge related to mouth care?

"I remove white patches on my tongue and cheeks with my toothbrush."

A nurse determines that an adolescent with a fractured left femur understands the instructions to perform only touch-down weight-down bearing when making what statement?

"I will allow my left leg to touch the floor without placing weight on it."

The nurse is caring for an adolescent client who asks that no information be shared with the client's caregivers. How should the nurse respond? Select all that apply.

"If you share information that suggests you or someone else is in danger, I have to share this with the appropriate authorities." "Information you share with me related to your health and lifestyle activities will not be shared directly with your caregivers." "If there are an costs associated with your care for which your caregivers will be billed, they would receive a statement of care provided."

After a nurse reinforces education with an adolescent about syphilis, which statement by the adolescent indicates the need for further education?

"Shill is a rarely transmitted sexually."

A 13-year old tells the nurse, " I have not yet started my period, but all my friends have." Which nursing response is appropriate?

"Some individuals do not start menstruating until age 15 or 16."

A nurse us reviewing infection-control measures with a group of unlicensed personnel (UAP). Which statement made by one of the group members indicates learning goals been met?

"Standard precautions should be used when performing client care."

An adolescent who is sexually active seeks counseling form the school nurse about the prevention of sexually transmitted infections (STIs). Which suggestion does the nurse make?

"Use condoms each time you have sexual intercourse."

An adolescent client was offered a babysitting job after school. The nurse coaches the parents to make which response to the client?

"What thought have you given as to how you'll manage your responsibilities?"

A 15-year-old boy wants to try out for the football team. His parents are concerned that because he' small for his age, he might be subjecting to ridicule. Which response by the parents best supports the adolescent's decision-making progress?

"Whether or not you play football is your decision; tell us why you want to play."

A RN and LPN are reviewing the charts of their assigned clients. The LPN asks which clients the RN would identify as clients that may qualify for hospice care? Select all that apply.

A client cirrhosis/liver failure and encephalopathy A client with late-stage AIDS

A nurse-manager is reviewing incidents that occurred recently. For which event will the manager need to make a report to the board of nursing?

A nurse documents administering narcotics to a client while personally using the medication

A client with terminal breast cancer is being cared for by a long-time friend who is a physician. The client has identified her sister as the agent in her healthcare power of attorney. The client loses decision-making capacity, the sister tells the nurse, "A different physician will be caring for my sister now. I've dismissed her friend." In response, the nurse should

Abide by the wishes of the sister who holds the durable power of attorney

The nurse witnesses a client with a known anxiety disorder begin to hyperventilate and state, "My chest is hurting." Which nursing intervention is appropriate?

Accompany the client to a quiet location, and provide instructions in a shirt, simple statements

A client arrives in the emergency department with hives and redness after a bee sting stating "I can't breathe! I am going to die." What action is anticipated by the nurse?

Administer an injection of epinephrine stat.

A client admitted to the acute psychiatric care unit after 2 weeks of increasingly erratic behavior. The client has been sleeping poorly, has lost 8 lb (3.3 kg), is poorly exhibits hyperactivity and loudly denies the need for hospitalization. Which nursing intervention takes priority for this client?

Administering a sedative as prescribed

The nursing team consists of one RN, one LPN, and one unlicensed assistive personnel (UAP). Which assignment should the RN delegate to the LPN?

Administrating daily am medications

A parent reports that their teenager is losing hair in small, round areas on the scalp. The nurse interprets this as suggesting which condition?

Alopecia

A charge nurse tells a new nurse, "you really need to get your skills up to speed." The statement hurts and embarrasses the new nurse. How can the new nurse best handle the situation?

Ask for a private meeting to explore the charge nurse's concerns in detail

Which intervention should the nurse implement to promote adequate nutritional intake for a client with Alzheimer's disease?

Assist the client with feeding

A nurse assists in writing a community plan for responding to a bio Terri's medical threat or attack. When reviewing the plan, the director of emergency operations should have the nurse correct which intervention?

Clients exposed to anthrax should immediately remove contaminated clothing and place it in the hamper.

While packing a client's abdominal wound with sterile, half-inch iodoform gauze, a nurse drops some of the gauze onto the client's abdomen, 2 inches (5 cm) away from the wound. What is the PRIORITY action by the nurse?

Discard the gauze packing and repack the wound with new iodoform gauze.

At the completion of a shift, the nurse is participating in the nursing handoff during the transition fro the day shift to the evening shift. At the time of shift change, there are not enough evening nurses to meet mandated nurse-client ratios. What is the nurse's BEST action?

Document the situation, and remain on the unit sufficient staffing levels are achieved

An unconscious, intoxicated client who took an overdose of an opioid receives naloxone to reverse the effect of the opioid. After the client awakens, what is the PRIORITY action by the nurse?

Educate the client on the effect of taking the pills and alcohol together

A nurse us caring for a client which a neuromuscular condition who is unable to receive oral nutrition. Which nursing action is a priority when providing continuous enteral feeding?

Elevating the head of the bed at least 30 degrees

A client who recently developed paralysis of the arms is diagnosed with functional neurologic symptom disorder after tests fail to uncover a physical cause for the paralysis. Which intervention should the nurse include in the plan of care?

Exercising the client's arms regularly

A 16-year-old comes to the physician's office for a physical examination that's required to play sports. The mother reports that her son is unusually tired during the day. She explains that he works at a part-time job, is socially active, gets about 7 hours of sleep each night. Physical examination reveals that the client grew 3" during the past year. Which intervention by the nurse is most appropriate?

Explaining that his sleep requirements have increased related to the increased metabolic demands of growth

An older adult client postoperative for a fractured right femur develops a cure shortness of breath and progressive hypoxia requiring mechanical ventilation. What is the MOST likely cause of this hypoxia?

Fat embolism (long bone fractures are correlated with fat emboli, which cause shortness of breath and hypoxia. It's unlikely the client has developed asthma or bronchitis without a previous history. Could develop atelectasis, but typically doesn't produce progressive hypoxia)

A 3-year-old child is receiving ampicillin for acne epiglottis. Which sign would lead the nurse to suspect that the child is experiencing a common adverse effect of this drug?

Generalized rash

A adolescent client comes to the emergency department with a acute asthma. The respiratory rate is 44 breaths/minute, and the client is experiencing severe respiratory distress. What is the PRIORITY nursing action by the nurse?

Give a bronchodilator by nebulizer

A nurse is reluctant to provide care at an accident scene. Which of the following legal definitions is true regarding the provision of nursing care?

Good Samaritan laws are designed to protect the caregiver in emergency situations.

A nurse is preparing to bathe a client hospitalized for emphysema. Which nursing intervention is correct?

Keep the head of the bed elevated during the procedure

While shopping at a mall, a woman experiences an episode of extreme terror accompanied by anxiety, tachycardia, trembling, and fear of going crazy. A friend drives her to the emergency department, where a physician rules out physiological causes and refers her to the psychiatric resident on call. The nurse caring for this client would expect the health care practitioner to prescribe which medication to control the client's anxiety?

Lorazepam (Lorazepam is a schedule IV drug used to treat anxiety. Reducing the client's anxiety will help her cope with stress)

While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply?

Moist sterile saline gauze

The nurse us working with an adolescent female diagnosed with scoliosis. What problem is commonly encountered by this group?

Poor self-esteem

An LVN/LPN working on a busy unit decides to delegate some tasks to the unlicensed assistive personnel (UAP). Which client tasks can be delegated to the UAP? Select all that apply.

Positioning a client intake and output measurement ambulation of a client

Which factor does the nurse inform the parents will place a child at increased risk for an asthma related death?

Prior admission to an intensive care unit for asthma

A nurse is caring for a client with a history of falls. Which interventions take PRIORITY in this client's care. Select all that apply.

Provide immediate response to the client's toileting needs Place the call light within client's reach Keep the bed in the lowest possible position

The nurse is working with a client with panic disorder who is currently experiencing a panic attack. Place the nursing interventions in the order in which the nurse will perform them. All options must be used.

Provide safety for the client and others in the environment instruct the client to focus on the nurse reassure the client that the nurse will remain with them during the attack reinforce that these symptoms mean the client is experiencing a panic attack ask the client what happened before the attack began help the client formulate a plan of action for the next time symptoms begin.

An adolescent client with diabetes checks the blood glucose at 9:00 p.m. before going to bed. It has been 4 hours since dinner and the regular insulin dose. The current blood glucose is 60 mg/dl (3.3 moles/L). The client feels a little "shaky." Which action does the nurse take?

Provide the client with a snack

The nurse is caring for a client that is scheduled for a surgical procedure. What explanation will the nurse give to the client for reinforcing pre operative education?

Providing general information, answering questions, and offering emotional support to the client and family

A nurse brings gifts and appears flirtatious with an older adolescent client. When a coworker confronts the nurse, the nurse replies, "We both know it's just in fun." How should the coworker respond?

Report the observations the nurse manager

A hospitalized is receiving pain medication. The nurse is providing instruction to the unlicensed assistive personnel (UAP) about the care of this client. Which takes would be appropriate to delegate to the UAP?

Reposition the client for comfort

A nurse us providing home care to a client who had failing vision. The nurse is concerned about the client's safety. Which action should the nurse take to help reduce the client's risk of a fall?

Request that the family have handrails installed o the stairs, in hallways, and in bathrooms

A nurse is caring for a client with dyspnea who has a resting respiratory rate of 44 breaths/minute and dusky nail beds. Arterial blood gases are obtained, and the results are as follows: pH, 7.52; PaO2, 50 mm Hg; PaCO2, 28 mm Hg; HCO3-, 24 mEq/L. The nurse knows these results are consistent with which condition?

Respiratory alkalosis

A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes highest priority for the client at this time?

Risk for injury

A nurse is assigned to care for an older adult client who is confused and repeatedly attempts to climb out of bed. While the nurse is out of the rim, the client climbs out of bed and falls, but does not sustain injuries from the falls, but does not sustain injuries fro the fall. This situation would MOST likely present as which type of occurrence?

Risk-management incident

Which of the following immunizations should the adolescent, age 12, receive as a component of preventative care?

Tetanus and diphtheria toxoids

The nurse is gathering data from a client that arrives in the clinic with generalized anxiety disorder (GAD). What statement made by the client does the nurse determine correlates with this diagnosis?

"I worry about things all of the time that I have no control over."

The nurse is teaching a group of adolescent clients about personal hygiene. Which client statement indicates the need for further teaching?

"It's unsafe to swim during your period."

A young adult was told that he had a significant reaction to the Mantoux test. The client asks the nurse what is the meaning of this significant reason. How does the nurse appropriately respond?

"You have been exposed to tuberculosis."

The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein?

Baked beans, hamburger, and milk

A nurse on the psychiatric unit realizes that she typically fails to administer medications according to schedule. What's the best way for the nurse to improve her medication administration practice?

Evaluate her current practice and devise an improvement plan

The nurse is caring for an adolescent with syphills. What factor must the nurse determine before the client can be treated?

Existence of medication allergies

A scrub nurse in the operating room has which responsibility?

Handing surgical instruments to the surgeon

A client tells a nurse "I feel that I'm losing my mind!" The nurse interprets this statement as MOST commonly associated with which disorder?

Panic disorder

After a motor vehicle crash, a client has a chest tube inserted that begins to drain a large amount of dark red fluid. Which explanation best describes what caused this type of drainage from the chest tube insertion?

The client has experienced a hemothorax instead of a pneumothorax

A nurse changes the wet-to-dry dressing of a client who has an open abdominal incision. Which nursing intervention is appropriate?

Label the dressing with the date, time, and nurse's initials

The nurse is collecting data from an adolescent with pelvic inflammatory disease (PID). What symptoms are anticipated when reviewing data?

Lower abdominal pain and urinary tract symptoms

The nurse observes the unlicensed assistive personnel (UAP) delivering a food tray to the client prescribed a clear liquid diet. The nurse would intervene when which food product is seen on the food tray?

Vanilla yogurt

The nurse is caring for a client who wishes to stop medical treatment. Which action by the nurse BEST demonstrates the role of the nurse as a client advocate?

Communicate the client's wishes to the healthcare provider

A 15-year-old girl visits the neighborhood clinic seeking information on "how to keep from getting pregnant." What should the nurse say in response to her request?

"Can you tell me about the precautions you're taking now?"

Which guidelines define and regulate what the nurse may and may not do as a professional?

Nurse Practice Act

The nurse is gathering data from an adolescent client. What technique is BEST to use when developing rapport?

Asking open-ended questions

The physician orders hourly urine output measurements for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml ( 8 a.m.), 60 ml (9 a.m.). Based on these amounts, what should the nurse so?

Continue to monitor and record hourly urine output

A nurse is caring for an adolescent female with cystic fibrosis. Which statements about the course of cystic fibrosis are true? Select all that apply.

The client is at risk for developing diabetes Breast development is commonly delayed normal sexual relationships can be expected

A client arrives in the clinic and informs the nurse they were bitten by a tick about a week ago on the back and are concerned about having contracted Lyme disease. When gathering data from this client, what EARLY client clinical manifestations of Lyme disease should the nurse document? Select all that apply.

There is a "Bull's eye" rash on the back Swollen lymph nodes are present in the axillae The client reports fatigue for the last 2 days

A nurse is conducting a health class at the local middle school about testicular self-examination. What statement by a student would indicate a need for further teaching?

"I do not need to perform testicular self-exams until I become sexually active."

A nurse is presenting nutritional information to a client with a wound and encourages to the client to consume foods high vitamins A and C to facilitate wound healing. The nurse determines the client understands which food products to incorporate when the client makes which statements? Select all that apply

"I will make sure to add sweet potatoes to my diet." "I love eating cherries and strawberries, so I will make sure to add them to my diet."

An adolescent female at the health care clinic is considering having sexual intercourse. The client tells the nurse that she wants to begin taking oral contraception because "Because control pills would mean I don't have to worry about pregnancy or HIV." What is the MOST appropriate initial response from the nurse?

"The nurse will not protect you from getting sexually transmitted infections, and it isn't 100% effective for preventing pregnancy."

The health care provider prescribes penicillin potassium oral suspension 56/kg/day in four divided doses for a client with anorexia who weighs 25 kg. The medication dispensed by the pharmacy contains a dosage of 125 mg/5ml. How many milliliters of solution should the nurse administer with each dose? Record your answer using a whole number.

14 (25 kg/X=1 kg/56 mg X = 1,400 mg. Next divide the daily dosage by four doses to determine the dose to administer every 6 hours: X= 1,400 mg/4 doses X 350 mg/dose. The adolescent should receive 350 mg every 6 hours. Lastly, calculate the volume to give each dose by setting up this proportion: X/350 mg = 5ml/125 mg = 14 ml).

To collect a clean-catch midstream urine specimen from a female client, the nurse instructs her to clean the area at the external urinary meatus with a antiseptic. How should the client do this?

By swabbing the labia Minorca from front to back.

A adolescent client is hospitalized with anorexia nervosa. What data support a nursing diagnosis of disturbed body image?

The client expresses a fear of overeating at meals

The nurse is teaching a group of adolescents about automobile safety. Which is the most effective teaching method for this age-group?

Coordinating a panel of peers who were involved in motor vehicle accidents

The parents of an adolescent girl have recently learned that their daughter has a terminal illness. At first, try to cope, they display avoidance behaviors. Then they demonstrate behaviors that indicate possible acceptance of the diagnosis. Which of the following behaviors would indicate acceptance?

Expression of feelings, such as sorrow and anger, about the child's condition

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around he clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia?

Document the client's choice and re-assess pain in 1 hour

A client with a sprained ankle comes to the emergency department. When bandaging the client's ankle, the nurse should use which technique?

Figure-eight *used for ankle, elbow, wrist, or knee, to support the joint and limit joint movement.

The nurse us performing her morning assessment when the client says, "I had trouble sleeping last night." Which action should the nurse take first?

Gathering more information about the sleep problem

A 13-year-old visits the school nurse experiencing back pain, fatigue, and dyspnea. The nurse suspects that the child may have scoliosis. What is the nurse's FIRST action?

Inspect the child for uneven shoulder height or uneven hip height.

After an outbreak of pinworms in a kindergarten class, the school nurse is reinforcing education with the parents. What should the nurse advise the parents to do to prevent the spread of pinworms?

Instruct their children not to bite their fingernails

A nurse is administering eye drops to a client with glaucoma. To achieve maximum absorption, where in the eye should the nurse instill the eye drops?

Into the conjunctival sac

An adolescent female client has begun menstruation. The nurse teaches the client about dietary intake of which nutrient related to this development?

Iron

A client admitted with dehydration has urinary incontinence and excoriation in the perineal area. Which action would be a PRIORITY?

Keeping the perineal area clean and dry

A healthcare provider obtains informed consent for a surgical procedure after the adult client had received sedation. Which is the nurse's BEST action?

Notify the healthcare provider that consent is not valid

A client arrives on the psychiatric unit exhibiting extreme excitement, disorientation, incoherent speech, agitation, frantic and aimless physical activity, and grandiose delusion. Which nursing diagnosis takes HIGHEST priority for this client at this time?

Risk for injury

A community health nurse is working disaster relief immediately after a flood. Which interventions would be a PRIORITY following this crisis? Select all apply.

Securing physical care Finding safe housing for the survivors Screening for waterborne diseases

An adolescent presents to a community clinic for treatment of vulvar lesions associated with Type 2 herpes simplex. Which action does the nurse take?

Show the adolescent to a private examination room for further assessment

An adolescent is admitted to the pediatric unit for evaluation of abdominal pain. Which individuals should collaborate in caring for this client? Select all that apply.

Social worker pharmacist physician nurse client

A school nurse suspects that a 13-year-old has structural scoliosis. Asking the adolescent to perform which maneuver would be the nurse's PRIORITY when gathering data for this condition?

The child bends over and touches the nurse observes from behind.