Level: Clinical
Difficulty: Medium
Subtopic: Communicable disease reporting
NCLEX: The home health nurse during an initial home visit is being evaluated for community health nursing and communicab…
Community / public health nursing Health Promotion and Maintenance
Case Study
The home health nurse during an initial home visit is being evaluated for community health nursing and communicable disease reporting. Assessment data include a neighborhood screening event identifies multiple clients with blood pressure above 180/100 mm Hg. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: B. 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.