Health assessment · practice question

A 66-year-old client in an outpatient clinic is being evaluated for pain assessment during hospitalization. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. 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.Implement the final step of the care plan before assessing the client.Give a blanket answer that everything is fine and continue the prior plan.Document the client as stable without reassessment.

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 66-year-old client in an outpatient clinic is being evaluated for pain assessment during hospitalization. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Which nursing action should the nurse take first?

Correct answer

Why

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