Physiological Adaptation Practice Question

Question

The nurse is caring for a client with heart failure and is focused on acute pain with physiologic instability scenario 13. Which nursing action is most appropriate?

Answer choices

1. A. Delay assessment until the next scheduled round if the client is not calling for help.
2. B. Assess pain while also evaluating vital signs and signs of complications.
3. C. Delegate the clinical assessment and nursing judgment to assistive personnel.
4. D. Document the concern without notifying the appropriate provider or care team member when escalation is needed.

Correct Answer

B. Assess pain while also evaluating vital signs and signs of complications.

Explanation

The priority action for acute pain with physiologic instability is to assess pain while also evaluating vital signs and signs of complications. NCLEX-style prioritization favors safety, assessment, appropriate delegation, timely escalation, and client-centered teaching.

Question details

• Difficulty: medium
• Domain: Physiological Adaptation
• Objective: acute pain with physiologic instability

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