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 assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
B. Screen for instability, then perform a focused assessment related to the presenting concern.
C. Use only the chart from admission without current data.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: B. Screen for instability, then perform a focused assessment related to the presenting concern.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.
Rationale: Assessment begins with stability screening and focused data collection before invasive or delayed actions.
Hint: Apply ABCs, client stability, and NCSBN clinical judgment steps before choosing an intervention.