Adult health / medical-surgical nursing · practice question
A 45-year-old client in the emergency department is being evaluated for chronic kidney disease with fluid overload. Assessment data include the client reports worst headache of life with neck stiffness. Which nursing action is the priority to keep the client safe?
Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg
Answer and explanation
Correct answer
B. Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.
Why
Client safety requires direct assessment, hazard reduction, and timely escalation rather than assumptions, abandonment, or policy-only actions.
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