Level: Foundational
Difficulty: Easy
Subtopic: Cardiac conduction and perfusion
NCLEX: A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to cardiac conduction…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to cardiac conduction and perfusion. Assessment data include a family member reports the client seems confused since this morning. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Pain relief before checking airway and breathing.
B. Visitor concerns before physiologic stability.
C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
B. Visitor concerns before physiologic stability.
C. Airway, breathing, and circulation problems before comfort or psychosocial needs.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: C. 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.