Level: Foundational
Difficulty: Easy
Subtopic: Recognize cues
NCLEX: A client in an unfolding case study is being evaluated for unfolding changes in a case study. Assessment data inc…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
A client in an unfolding case study is being evaluated for unfolding changes in a case study. Assessment data include the medication record, labs, and assessment notes contain conflicting cues. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.