Level: Foundational
Difficulty: Easy
Subtopic: Adolescent development
NCLEX: A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent development. Assessment data include the adolescent reports feeling unsafe in a dating relationship. 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. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
B. Implement the final step of the care plan before assessing the client.
C. Document the client as stable without reassessment.
D. Delegate the initial assessment and clinical judgment to unlicensed assistive personnel.
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.