Level: Foundational
Difficulty: Easy
Subtopic: Neurologic assessment
NCLEX: A 49-year-old client in the emergency department is being evaluated for neurologic assessment during hospitalizat…
Health assessment Reduction of Risk Potential
Case Study
A 49-year-old client in the emergency department is being evaluated for neurologic assessment during hospitalization. Assessment data include respiratory rate 8/min, shallow breathing, and SpO2 86% on room air. Before teaching, what should the nurse assess first?
Question
A. Begin a long lecture while the client is in acute distress.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
B. Immediate safety, readiness to learn, literacy, cultural needs, barriers, and baseline understanding.
C. Assume understanding without checking literacy or readiness.
D. Delegate all teaching without RN evaluation of learning needs.
Rationale
Correct answer: B. 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.