Nursing fundamentals · practice question
An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to hygiene and comfort. 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-2026nursing-fundamentals
Answer and explanation
Correct answer
D. 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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