Level: Clinical
Difficulty: Medium
Subtopic: Gastrointestinal digestion and absorption
NCLEX: A 59-year-old client in the intensive care unit is being evaluated for nursing care related to gastrointestinal d…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 59-year-old client in the intensive care unit is being evaluated for nursing care related to gastrointestinal digestion and absorption. Assessment data include client appears anxious and asks for help understanding the care plan. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: B. 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.