Level: Clinical
Difficulty: Medium
Subtopic: Advance directives
NCLEX: A 39-year-old client in the emergency department is being evaluated for nursing care related to advance directive…
Ethics, legal nursing, delegation, prioritization Management of Care
Case Study
A 39-year-old client in the emergency department is being evaluated for nursing care related to advance directives. Assessment data include new chest pain rated 8/10 with diaphoresis. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Use only the chart from admission without current data.
C. Defer assessment until all medications are administered.
D. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale
Correct answer: D. 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.