Level: Advanced
Difficulty: Hard
Subtopic: Delegation rules
NCLEX: A 39-year-old client in the emergency department is being evaluated for a busy medical-surgical assignment. Asses…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 39-year-old client in the emergency department is being evaluated for a busy medical-surgical assignment. Assessment data include UAP reports the client fell in the bathroom. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.