Level: Clinical
Difficulty: Medium
Subtopic: Screening programs
NCLEX: The community health nurse at a public health clinic is being evaluated for community health nursing and screenin…
Community / public health nursing Health Promotion and Maintenance
Case Study
The community health nurse at a public health clinic is being evaluated for community health nursing and screening programs. Assessment data include a home visit reveals no working smoke detectors and medications stored on the floor. Which nursing action should the nurse take first?
Question
A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
Rationale
Correct answer: A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.