Pathophysiology · practice question

A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. Assessment data include the client reports worst headache of life with neck stiffness. Using the clinical judgment model, what is the nurse's first step?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026pathophysiology

Document the assessment at the end of the shift and continue the prior plan.Evaluate discharge readiness before addressing acute findings.Recognize and analyze relevant cues to determine whether the client is stable or deteriorating.Implement the first intervention on the existing care plan without reviewing new data.

Answer and explanation

Correct answer

C. 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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A 68-year-old client on a medical-surgical unit is being evaluated for nursing care related to hypoxia and impaired gas exchange. Assessment data include the client reports worst headache of life with neck stiffness. Using the clinical judgment model, what is the nurse's first step?

Correct answer

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