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 client has unintentional weight loss and difficulty preparing meals. 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. Document the finding and recheck at the end of the shift without further assessment.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
B. Document the client as stable without reassessment.
C. Document the finding and recheck at the end of the shift without further assessment.
D. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
Rationale
Correct answer: D. 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.