Level: Advanced
Difficulty: Hard
Subtopic: Musculoskeletal assessment
NCLEX: A 49-year-old client in the emergency department is being evaluated for musculoskeletal assessment during hospita…
Health assessment Reduction of Risk Potential
Case Study
A 49-year-old client in the emergency department is being evaluated for musculoskeletal assessment during hospitalization. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Pain relief before checking airway and breathing.
B. Visitor concerns before physiologic stability.
C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
B. Visitor concerns before physiologic stability.
C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.