Level: Clinical
Difficulty: Medium
Subtopic: Young adult development
NCLEX: A 24-year-old client in an outpatient clinic is being evaluated for developmental expectations for young adult de…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 24-year-old client in an outpatient clinic is being evaluated for developmental expectations for young adult development. Assessment data include the client reports work stress, poor sleep, and increased alcohol use. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Complete nonurgent tasks first because the client appears calm.
B. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
C. Complete all remaining scheduled tasks before reassessing the client.
D. Complete nonurgent tasks first because the client appears calm.
Rationale
Correct answer: B. 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.