Adult health / medical-surgical nursing · practice question
A 59-year-old client in the intensive care unit is being evaluated for acute stroke symptoms. Assessment data include temperature 102.2°F (39°C), heart rate 126/min, blood pressure 86/50 mm Hg, and confusion. Which assessment approach should the nurse use first?
Multiple choiceEasynclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg
Answer and explanation
Correct answer
C. Screen for instability, then perform a focused assessment related to the presenting concern.
Why
Assessment begins with stability screening and focused data collection before invasive or delayed actions.
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