Health assessment · practice question

A 49-year-old client in the emergency department is being evaluated for neurologic assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which nursing action should the nurse take first?

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

Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.Document the client as stable without reassessment.Implement the final step of the care plan before assessing the client.Complete nonurgent tasks first because the client appears calm.

Answer and explanation

Correct answer

A. Perform a focused assessment for immediate risk, then implement the safest intervention per protocol.

Why

First-action questions on the NCLEX require assessment and safety before treatment, documentation alone, or delegation of nursing judgment.

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A 49-year-old client in the emergency department is being evaluated for neurologic assessment during hospitalization. Assessment data include the client tries to get out of bed unassisted and becomes unsteady. Which nursing action should the nurse take first?

Correct answer

Why

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