Level: Clinical
Difficulty: Medium
Subtopic: Renal and urinary disorders
NCLEX: A 45-year-old client in the emergency department is being evaluated for chronic kidney disease with fluid overloa…
Adult health / medical-surgical nursing Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for chronic kidney disease with fluid overload. Assessment data include the client reports worst headache of life with neck stiffness. Which nursing action is the priority to keep the client safe?
Question
A. Leave the client alone to promote independence while finishing charting.
B. Apply the first intervention in the policy manual without a current assessment.
C. Give a blanket answer that everything is fine and continue the prior plan.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
B. Apply the first intervention in the policy manual without a current assessment.
C. Give a blanket answer that everything is fine and continue the prior plan.
D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale
Correct answer: D. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.