Level: Foundational
Difficulty: Easy
Subtopic: Analyze cues
NCLEX: A client in an unfolding case study is being evaluated for nursing care related to analyze cues. Assessment data…
Clinical judgment / Next Gen NCLEX case studies Clinical Judgment
Case Study
A client in an unfolding case study is being evaluated for nursing care related to analyze cues. Assessment data include the client improves after the initial intervention but develops a new safety concern. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Teaching is effective only after safety and learning readiness are confirmed; the RN cannot delegate assessment of learning needs on unstable clients.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.