Level: Clinical
Difficulty: Medium
Subtopic: Neurologic control and level of consciousness
NCLEX: A 45-year-old client in the emergency department is being evaluated for nursing care related to neurologic contro…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 45-year-old client in the emergency department is being evaluated for nursing care related to neurologic control and level of consciousness. Assessment data include vital signs change from earlier: blood pressure 94/60 mm Hg and heart rate 112/min. Which action is appropriate within the RN scope of practice?
Question
A. Independently diagnose the medical disease and prescribe treatment.
B. Prescribe new medications without a provider order.
C. Delegate nursing assessment and evaluation on an unstable client.
D. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
B. Prescribe new medications without a provider order.
C. Delegate nursing assessment and evaluation on an unstable client.
D. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale
Correct answer: D. Assess, analyze cues, implement nursing interventions per orders, teach, evaluate outcomes, and question unsafe orders.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: RNs assess, coordinate care, teach, and evaluate. Diagnosis and prescribing are provider responsibilities.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.