Level: Foundational
Difficulty: Easy
Subtopic: General survey
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for nursing care related to general survey. Asses…
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for nursing care related to general survey. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which error is most dangerous on the NCLEX and in practice?
Question
A. Teaching the client after stability is confirmed.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
B. Reassessing the client after an appropriate intervention.
C. Using SBAR to notify the provider about abnormal findings.
D. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale
Correct answer: D. Choosing an intervention before identifying assessment cues and immediate safety risk.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: The most dangerous NCLEX trap is treating before assessing, which can miss life-threatening deterioration.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.