Nursing fundamentals · practice question
An 82-year-old client on a medical-surgical unit is being evaluated for nursing care related to skin integrity. Assessment data include the client reports no sleep and increasing agitation overnight. Which assessment approach should the nurse use first?
Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026nursing-fundamentals
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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