Level: Foundational
Difficulty: Easy
Subtopic: Inflammation and cellular injury
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to inflammation and…
Pathophysiology Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to inflammation and cellular injury. Assessment data include the client reports worst headache of life with neck stiffness. Which action is appropriate within the RN scope of practice?
Question
A. Independently diagnose the medical disease and prescribe treatment.
B. Prescribe new medications without a provider order.
C. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
D. Delegate nursing assessment and evaluation on an unstable client.
B. Prescribe new medications without a provider order.
C. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
D. Delegate nursing assessment and evaluation on an unstable client.
Rationale
Correct answer: C. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.