Level: Clinical
Difficulty: Medium
Subtopic: Skin and wound assessment
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for skin and wound assessment during hospitalizat…
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for skin and wound assessment during hospitalization. Assessment data include temperature 100.8°F (38.2°C) with rigors and chills. 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.