Level: Advanced
Difficulty: Hard
Subtopic: Family systems
NCLEX: A client in an outpatient clinic is being evaluated for nursing care related to family systems. Assessment data i…
Psychology / lifespan development Health Promotion and Maintenance
Case Study
A client in an outpatient clinic is being evaluated for nursing care related to family systems. Assessment data include the client has not slept in 3 days and speech is rapid and pressured. 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. Give a blanket answer that everything is fine and continue the prior plan.
B. Document the client as stable without reassessment.
C. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.
D. Give a blanket answer that everything is fine and continue the prior plan.
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.