Level: Foundational
Difficulty: Easy
Subtopic: Adolescent development
NCLEX: A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 16-year-old adolescent at a primary care visit is being evaluated for developmental expectations for adolescent development. Assessment data include screening reveals vaping, poor sleep, and declining grades. Which action should the nurse take first?
Question
A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Give a blanket answer that everything is fine and continue the prior plan.
B. Offer a warm blanket and reschedule assessment until after lunch.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Give a blanket answer that everything is fine and continue the prior plan.
Rationale
Correct answer: A. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: NCLEX priority questions require stabilizing the client first using ABCs and focused assessment before comfort measures, documentation only, or delayed escalation.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.