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 blood pressure screening is 168/96 mm Hg at two visits. Which assessment approach should the nurse use first?
Question
A. Begin invasive procedures before any focused assessment.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
B. Use only the chart from admission without current data.
C. Screen for instability, then perform a focused assessment related to the presenting concern.
D. Defer assessment until all medications are administered.
Rationale
Correct answer: C. 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.