Level: Clinical
Difficulty: Medium
Subtopic: Middle adult development
NCLEX: A 48-year-old client at an annual wellness visit is being evaluated for developmental expectations for middle adu…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 48-year-old client at an annual wellness visit is being evaluated for developmental expectations for middle adult development. Assessment data include the client is overdue for recommended cancer screening. Which nursing action should the nurse take first?
Question
A. Implement the final step of the care plan before assessing the client.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Tell the client symptoms are expected and avoid notifying the health care team.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Tell the client symptoms are expected and avoid notifying the health care team.
Rationale
Correct answer: C. 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.