Adult health / medical-surgical nursing · practice question

A 59-year-old client in the intensive care unit is being evaluated for partial bowel obstruction. Assessment data include the client reports worst headache of life with neck stiffness. Which assessment approach should the nurse use first?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026adult-health-med-surg

Begin invasive procedures before any focused assessment.Defer assessment until all medications are administered.Use only the chart from admission without current data.Screen for instability, then perform a focused assessment related to the presenting concern.

Answer and explanation

Correct answer

D. 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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A 59-year-old client in the intensive care unit is being evaluated for partial bowel obstruction. Assessment data include the client reports worst headache of life with neck stiffness. Which assessment approach should the nurse use first?

Correct answer

Why

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