Health assessment · practice question

A 49-year-old client in the emergency department is being evaluated for skin and wound assessment during hospitalization. Assessment data include the client reports no sleep and increasing agitation overnight. Using the clinical judgment model, what is the nurse's first step?

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

Evaluate discharge readiness before addressing acute findings.Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.Document the assessment at the end of the shift and continue the prior plan.Implement the first intervention on the existing care plan without reviewing new data.

Answer and explanation

Correct answer

B. Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.

Why

NCSBN clinical judgment begins with recognizing and analyzing cues before taking action or evaluating outcomes.

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A 49-year-old client in the emergency department is being evaluated for skin and wound assessment during hospitalization. Assessment data include the client reports no sleep and increasing agitation overnight. Using the clinical judgment model, what is the nurse's first step?

Correct answer

Why

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