Nursing fundamentals · practice question
A 70-year-old client in a rehabilitation facility is being evaluated for nursing care related to sleep and rest. Assessment data include blood pressure 180/102 mm Hg with headache and blurred vision. Using the clinical judgment model, what is the nurse's first step?
Multiple choiceHardnclex-rn-bsnnclex-validatednclex-2026nursing-fundamentals
Answer and explanation
Correct answer
A. 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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