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 is planning pregnancy and asks about folic acid and medication safety. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
C. Document the client as stable without reassessment.
D. Apply restraints without assessing less restrictive safety options first.
Rationale
Correct answer: B. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.