Level: Advanced
Difficulty: Hard
Subtopic: Interprofessional communication
NCLEX: The RN on a telemetry unit is being evaluated for nursing care related to interprofessional communication. Assess…
Leadership and management Management of Care
Case Study
The RN on a telemetry unit is being evaluated for nursing care related to interprofessional communication. Assessment data include UAP reports the client fell in the bathroom. Which assessment approach should the nurse use first?
Question
A. Screen for instability, then perform a focused assessment related to the presenting concern.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Begin invasive procedures before any focused assessment.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: A. 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.