Level: Advanced
Difficulty: Hard
Subtopic: Focused reassessment
NCLEX: A 66-year-old client in an outpatient clinic is being evaluated for focused reassessment during hospitalization….
Health assessment Reduction of Risk Potential
Case Study
A 66-year-old client in an outpatient clinic is being evaluated for focused reassessment during hospitalization. Assessment data include the client has not voided in 8 hours and lower abdomen is firm and tender. 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. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. 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.