Health assessment · practice question

A 49-year-old client in the emergency department is being evaluated for head and neck assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which nursing action is the priority to keep the client safe?

Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026health-assessment

Leave the client alone to promote independence while finishing charting.Tell the client symptoms are expected and avoid notifying the health care team.Apply the first intervention in the policy manual without a current assessment.Stay with the client, remove immediate hazards, reassess, and escalate per facility safety protocol.

Answer and explanation

Correct answer

D. 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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A 49-year-old client in the emergency department is being evaluated for head and neck assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which nursing action is the priority to keep the client safe?

Correct answer

Why

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