Level: Clinical
Difficulty: Medium
Subtopic: Falls prevention
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for high fall risk on a medical unit. Assess…
Nursing fundamentals Basic Care and Comfort Safety and Infection Prevention and Control
Case Study
A 76-year-old client in a long-term care facility is being evaluated for high fall risk on a medical unit. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Using ABCs and Maslow, which need should the nurse address first?
Question
A. Airway, breathing, and circulation problems before comfort or psychosocial needs.
B. Pain relief before checking airway and breathing.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
B. Pain relief before checking airway and breathing.
C. Visitor concerns before physiologic stability.
D. Long-term teaching before treating acute physiologic risk.
Rationale
Correct answer: A. Airway, breathing, and circulation problems before comfort or psychosocial needs.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Physiologic stability and ABCs take priority over comfort, teaching, or psychosocial needs when the client is unstable.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.