Level: Advanced
Difficulty: Hard
Subtopic: Neurologic injury
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to neurologic injury….
Pathophysiology Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to neurologic injury. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Pain relief before checking airway and breathing.
B. Airway, breathing, and circulation problems before comfort or psychosocial needs.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
B. Airway, breathing, and circulation problems before comfort or psychosocial needs.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: B. 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.