Level: Clinical
Difficulty: Medium
Subtopic: Older adult changes
NCLEX: A 78-year-old client in a long-term care facility is being evaluated for nursing care related to older adult chan…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A 78-year-old client in a long-term care facility is being evaluated for nursing care related to older adult changes. Assessment data include the caregiver reports new confusion since yesterday morning. Which action should the nurse take first?
Question
A. Offer a warm blanket and reschedule assessment until after lunch.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Apply restraints without assessing less restrictive safety options first.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
B. Complete all remaining scheduled tasks before reassessing the client.
C. Apply restraints without assessing less restrictive safety options first.
D. Assess airway, breathing, and circulation; address immediate safety risk; then notify the provider per protocol.
Rationale
Correct answer: D. 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.