Health assessment · practice question

A 49-year-old client in the emergency department is being evaluated for pain assessment during hospitalization. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which assessment approach should the nurse use first?

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

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

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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A 49-year-old client in the emergency department is being evaluated for pain assessment during hospitalization. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which assessment approach should the nurse use first?

Correct answer

Why

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