Level: Advanced
Difficulty: Hard
Subtopic: Pain basics
NCLEX: A 76-year-old client in a long-term care facility is being evaluated for nursing care related to pain basics. Ass…
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 nursing care related to pain basics. Assessment data include pain 9/10 and guards the abdomen after surgery. 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.