Level: Advanced
Difficulty: Hard
Subtopic: Head and neck assessment
NCLEX: A 74-year-old client on a medical-surgical unit is being evaluated for head and neck assessment during hospitaliz…
Health assessment Reduction of Risk Potential
Case Study
A 74-year-old client on a medical-surgical unit is being evaluated for head and neck assessment during hospitalization. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. 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. Long-term teaching before treating acute physiologic risk.
D. Airway, breathing, and circulation problems before comfort or psychosocial needs.
B. Visitor concerns before physiologic stability.
C. Long-term teaching before treating acute physiologic risk.
D. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale
Correct answer: D. 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.