Level: Advanced
Difficulty: Hard
Subtopic: Musculoskeletal structure and mobility
NCLEX: A 62-year-old client on a postoperative unit is being evaluated for nursing care related to musculoskeletal struc…
Anatomy & Physiology I/II Physiological Adaptation
Case Study
A 62-year-old client on a postoperative unit is being evaluated for nursing care related to musculoskeletal structure and mobility. Assessment data include a family member reports the client seems confused since this morning. Before teaching, what should the nurse assess first?
Question
A. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Begin a long lecture while the client is in acute distress.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: A. 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.